Comments on “Into the future: first robotic totally endoscopic coronary artery bypass in Southeast Asia”

Abstract

We read with great interest the report describing the first robotic totally endoscopic coronary artery bypass (TECAB) in Southeast Asia. While this achievement deserves recognition, we believe several aspects—including revascularization strategy, prolonged operative and recovery times, and the lack of intraoperative transit-time flow measurement—require further clarification to accurately interpret the clinical significance of this pioneering experience.

To the editor,

We read with great interest the article by Hanafy et al. describing the first robotic totally endoscopic coronary artery bypass (TECAB) performed in Southeast Asia [1]. The successful establishment of a robotic coronary surgery program in a new center deserves recognition, and the authors should be congratulated for transparently reporting the challenges encountered during their inaugural case.

Nevertheless, several aspects of the report merit further discussion.

First, although the patient was reported to have three-vessel coronary artery disease, only a left internal mammary artery-to-left anterior descending (LIMA-LAD) bypass was performed. The authors state that distal lesions in the circumflex and right coronary artery favored a single-vessel strategy; however, the presented angiographic images appear to show potentially graftable target vessels. Additional information regarding vessel caliber, distal runoff, functional significance, or the rationale for excluding surgical or hybrid revascularization of the remaining territories would help readers better understand the decision-making process. Since complete revascularization remains an important determinant of long-term outcomes, a more detailed justification would strengthen the report. Moreover, an uncomplicated early course after a single LIMA-LAD graft does not establish the adequacy of revascularization in a patient with three-vessel disease. Reporting the planned management of the untreated territories and longer-term clinical, functional, and angiographic follow-up—including recurrent angina, repeat revascularization, myocardial infarction, graft patency, and survival—would be essential for interpreting the actual outcome of this strategy.

Second, the reported operative duration of 545 min is remarkably prolonged, even for an inaugural TECAB procedure. While an extended operative time is expected during the learning phase, a procedure lasting more than nine hours has substantial consequences beyond operating-room occupancy. It requires prolonged deployment of the robotic platform, anesthesia, nursing, perfusion standby, technical support, disposable instruments, and recovery resources; therefore, the direct and opportunity costs should be acknowledged when assessing program feasibility. The authors could strengthen the report by providing a procedure-level cost or resource analysis and by comparing it with conventional or minimally invasive alternatives.

The clinical burden of such prolonged exposure also warrants discussion. Extended anesthesia, single-lung ventilation, tissue manipulation, and immobility may intensify surgical stress and inflammatory responses and may increase the risks of pulmonary complications, hypothermia, pressure injury, infection, and delayed recovery, potentially offsetting the anticipated advantages of a totally endoscopic approach [2]. Extubation occurred 22 h after surgery, and although the ICU stay was reported as 24 h, this effectively indicates transfer from intensive care only about two hours after extubation. Discharge on postoperative day 7 is likewise difficult to interpret as accelerated recovery. In addition to reporting early complications, the authors should clarify whether the patient was explicitly informed that the inaugural robotic approach might require a markedly longer operation, could require conversion, and would provide only partial surgical revascularization despite available conventional or hybrid alternatives. Documentation of the patient’s understanding and preference is especially important when the learning curve materially changes the expected duration and completeness of treatment [3].

Finally, we believe the absence of intraoperative transit-time flow measurement (TTFM) deserves greater emphasis. Objective graft assessment has become an essential quality assurance tool in contemporary coronary bypass surgery and is particularly valuable during the early learning curve of technically demanding procedures such as TECAB. In a center investing in robotic coronary surgery, the lack of TTFM arguably represents a more important limitation than many of the technical challenges discussed in the manuscript. Reliance solely on visual assessment and postoperative clinical stability cannot exclude suboptimal graft function [4].

Beyond the index case, the educational value of the report would be enhanced by describing the team’s preparation before clinical implementation. Specifically, the number and type of console simulations, dry-lab or wet-lab sessions, cadaveric procedures, team-based scenario rehearsals, proctored cases, and predefined competency or conversion criteria should be reported. Contemporary pathways for establishing robotic coronary programs emphasize stepwise progression, dedicated-team simulation, cadaver training, and proctoring before single-vessel and subsequently multivessel TECAB [3]. These data would allow readers to judge whether the 545-minute duration reflects an appropriately structured early learning curve and would offer more transferable guidance to emerging programs.

Despite these observations, the authors should be commended for openly sharing their initial experience, which provides valuable insight for other centers considering robotic coronary surgery. Further clarification regarding the completeness and longitudinal outcomes of revascularization, patient consent, resource utilization, perioperative burden, simulation-based preparation, and graft quality assessment would substantially enhance the educational value of this important report.

Author contributions

Safa Özçelik: Conceptualization, Literature review, Writing – original draft, Writing – review & editing, Critical revision of the manuscript, Final approval of the version to be published.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Declarations

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Competing interests

The authors declare no competing interests.