A group of enthusiastic surgeons and engineers working together in Stanford introduced the idea of “port access” cardiac surgery in humans in 1995.¹ Despite the initial enthusiasm from many surgical groups, the outcomes from this new approach did not match the high safety levels already achieved by sternotomy approaches, and this procedure largely fell out of favor. Three groups persisted with this idea. Dr Mohr in Leipzig popularized the direct vision through a minithoracotomy approach.² Dr Vanermen in Aalst showed excellent results with what was termed an “endoscopic” procedure, in which the procedure was guided by the view from an endoscope on a big screen.³ Dr Chitwood and his team at East Carolina University used the robot and telemanipulation to get very good results in mitral valve surgery.⁴ With time, more surgeons adopted 1 of these 3 approaches and gradually more patients benefitted from these nonsternotomy procedures, leading to a consensus statement supporting their wider use.⁵ Most case series and propensity-matched analyses of large databases did not show any advantages for both the direct vision approach or the robotic approach to the mitral valve. The cosmetic benefits were accepted, and the lack of harm was demonstrated by these papers.⁶ Propensity-matched studies of endoscopic approaches have shown a reduction in hospital stay by 1 day compared with the sternotomy approach, and this has been confirmed in a large randomized controlled trial.^7,8 This reduction is despite an increase in intraoperative bypass and cross-clamp times for the endoscopic approach. Endoscopic techniques come with a steep learning curve, and the process of moving safely from sternotomy to a totally endoscopic approach is a gradual transition that needs to be managed responsibly by the surgeon and the team.