Robotically assisted mitral valve repair—port-only totally endoscopic approach

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease. Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional aortic cross-clamping. Moreover, intercostal nerve cryoanesthesia is performed from T3–T9 to reduce post-operative pain and aid in reducing opioid management. Barbed, nonabsorbable sutures are used throughout the procedure (for left atrial appendage closure, mitral valve annuloplasty band placement, left atrial closure, pericardial re-approximation), eliminating the need for knot-tying at several steps. We also detail the installation of two sets of neochords for mitral regurgitation and the fastening of the mitral annuloplasty band. Finally, we would like to highlight the small size of each port used in the case (eight millimeters maximum diameter). Taken together, these features of the robotic platform make it notable for its minimally invasive approach to MVR.