Robotic multi-vessel off-pump totally endoscopic coronary artery bypass (TECAB) procedure: surgical technique

Robotic totally endoscopic coronary artery bypass (TECAB) is a highly advanced yet evolving surgical technique for coronary artery disease. While it is not yet a standard procedure, ongoing developments in robotic technology have positioned it as a promising option for the future. TECAB allows for multi-vessel coronary artery bypass using bilateral internal mammary artery (BIMA) grafts in a completely minimally invasive, off-pump approach. With over 15 years of experience performing TECAB, we have refined patient selection criteria and surgical techniques. Initially, pleural scarring or diffuse coronary artery disease were considered contraindications. However, the precision and magnification provided by robotic platforms have enabled us to expand indications, including for redo surgeries where internal mammary artery grafts are still viable. While the operation is typically limited to left coronary artery bypass, recent cases have demonstrated its feasibility for right coronary artery branches under specific conditions. We believe that the off-pump approach in this setting has significant advantages for early patient recovery and return to full function. While technically demanding we have demonstrated excellent graft patency and long-term outcomes with this procedure. In this video, we present our current technique for robotic multivessel off-pump TECAB using the da Vinci Si surgical system. We will outline patient presentation, surgical steps, and key technical insights to demonstrate how this minimally invasive approach continues to evolve and expand its clinical utility.