In the issue of the journal, Claessens et al. [1] present a large case series of non-robotic totally endoscopic coronary artery bypass (TECAB) surgery. They summarize the outcomes of 1500 patients who underwent non-robotic TECAB using 1 or 2 internal mammary artery grafts (for full arterial revascularization) on cardiopulmonary bypass with transthoracic aortic clamping. Their approach yielded favourable short-term results and 1-year freedom from major adverse cardiac and cerebrovascular events. Dr Yilmaz and the group from Belgium are to be congratulated on their results, as they have mastered this technique and made it reproducible in their hands.

TECAB surgery was 1st performed using a traditional videoscope and shafted instruments on a beating heart in 1999 [2]. This procedure was very complex and did not gain much traction. In the same year, the 1st report of telemanipulation using robotic wristed instruments and 3D visualization to perform TECAB was published [3]. This was followed by multiple centres reporting success with this technique where the heart was arrested using the Heartport™ endovascular clamp technology [4], followed by a multicentre FDA trial in the USA showing favourable results [5]. As coronary surgery on the beating heart via sternotomy off pump coronary artery bypass (OPCAB) and minithoracotomy coronary artery bypass (MIDCAB) were also gaining traction during this time, the stated goal of most robotic endoscopic surgeons who performed arrested heart single vessel TECAB was that it was a steppingstone to an off-pump and multivessel version of this operation. The introduction of a robotic endoscopic stabilizer several years later made this goal a reality [6].

While the authors are to be commended for pursuing an endoscopic approach in coronary bypass surgery, it is well known that the use of peripheral cardiopulmonary bypass and aortic cross clamping adds to the morbidity of the procedure, as coronary patients have a relatively high incidence of peripheral and cerebrovascular disease than, for example, patients with valvular heart disease.