Technical evolution of totally endoscopic coronary artery bypass on the da Vinci Xi platform: Lessons learned from the first 84 cases

Objective Previous studies have shown the safety and effectiveness of totally endoscopic coronary artery bypass. We report our initial experience performing totally endoscopic coronary artery bypass using the da Vinci Xi platform without an EndoWrist stabilizer, combining the GelPOINT Mini, AirSeal, and Nuvo Stabilizer. Methods All consecutive patients undergoing totally endoscopic coronary artery bypass were included from January 2024 to December 2025 from our center. The primary end point was to evaluate sternotomy conversion rates. Secondary end points consisted of mortality and major adverse cardiac and cerebrovascular events. Results During the study period, 84 patients underwent totally endoscopic coronary artery bypass. The mean age and body mass index were 63.6 ± 10.5 years and 30 ± 4.6 kg/m 2 , respectfully. The median left ventricular ejection fraction and hemoglobin A1c were 60.0% (58.0-65.0) and 5.7% (5.3-6.3), respectively. The median Society of Thoracic Surgeons score was 0.55 (0.35-0.86). Intraoperatively, the median left internal thoracic artery left anterior descending flow was 50.0 (40.0-61.5) mL/min. Thirty-one patients (36.9%) underwent totally endoscopic coronary artery bypass as part of a hybrid revascularization strategy, including 7 cases (8.3%) of reverse hybrid revascularization. Most patients (n = 52, 61.9%) were extubated in the operating room. There were no conversions to sternotomy, but 1 patient required reoperation for bleeding. Postoperatively, there were no strokes, myocardial infarctions, or deaths. The median hospital length of stay was 2.0 (1.0-3.0) days, and 98.8% (83/84) of patients were discharged directly home. At 30-day follow-up, there were no deaths. Conclusions This initial totally endoscopic coronary artery bypass experience enabled the identification of key technical challenges related to coronary stabilization, visualization, and suture management. The derived surgeon-driven solutions may guide future technology development and contribute to simplifying the procedure, improving reproducibility, and facilitating broader adoption of totally endoscopic coronary artery bypass.