Transitioning from direct vision to totally endoscopic minimally invasive cardiac surgery

Minimally invasive cardiac surgery (MICS) has evolved significantly over the past two decades, shifting from conventional median sternotomy toward sternal-sparing approaches that offer reduced surgical trauma, lower complication rates, and faster patient recovery. As incision size has progressively decreased, the field has advanced toward totally endoscopic cardiac surgery (TECS), in which the entire intracardiac procedure is performed exclusively under thoracoscopic visualization. Despite growing adoption, the transition from direct-vision MICS to TECS remains technically demanding and operationally complex. Drawing on our institutional experience at Brigham and Women's Hospital, Harvard Medical School, and a review of the current literature, we provide a comprehensive overview of the key elements required to successfully build and sustain a TECS program. These include a working definition of totally endoscopic surgery, a proposed four-phase surgeon training pathway, simulation-based learning strategies, robotic credentialing, team-based training, technical instrumentation, scope management, patient selection criteria, procedural challenges, and postoperative outcomes. Both non-robotic and robotic-assisted endoscopic platforms are discussed. Large-scale evidence confirms that MICS and TECS achieve outcomes equivalent or superior to sternotomy, with low mortality and stroke rates, and significantly improved health-related quality of life. Notably, non-robotic TECS offers a scalable and cost-effective pathway that does not require an expert bedside assistant, can address multiple pathologies simultaneously, and is feasible across diverse healthcare settings. Emerging technologies-including articulated robotic instruments, artificial intelligence-enhanced imaging, and next-generation robotic platforms-are expected to further expand the reach and safety of fully endoscopic cardiac procedures.