The mitral valve is conventionally accessed through a left atriotomy; however, adequate visualization may be challenging in selected patients, particularly those undergoing redo surgery, minimally invasive procedures, or with a small or non-compliant left atrium. In such cases, a transseptal interatrial approach can provide improved exposure of the mitral apparatus while facilitating concomitant tricuspid valve procedures. The limited transseptal (LTS) approach represents a partial, anatomy-preserving modification of the classic extended vertical transatrial septal incision. By confining the septal incision to the region of the fossa ovalis, and avoiding superior extension toward the atrial roof, this technique provides sufficient mitral valve exposure while minimizing the risk of injury to the sinus node artery and atrial conduction tissue. Alternative strategies, including the superior transseptal approach and the extended vertical transseptal incision have been associated with a higher incidence of atrial conduction disturbances and postoperative pacing requirements. In contrast, the LTS approach preserves atrial anatomy and reduces surgical trauma while maintaining excellent access to both atrioventricular valves. This video tutorial outlines the anatomical principles, indications and step-by-step surgical technique of the LTS approach, highlighting technical pearls and potential pitfalls to facilitate its safe and reproducible application in contemporary mitral valve surgery.
Surgical revascularization carries a class I recommendation for the treatment of ischaemic cardiomyopathy and multivessel coronary artery disease, yet coronary artery bypass grafting carries substantial risk of postoperative low cardiac output syndrome and subsequent mortality in patients with severe left ventricular systolic dysfunction. Off-pump coronary artery bypass grafting avoids cardiopulmonary bypass and cardioplegic arrest, but may not be feasible in severe left ventricular systolic dysfunction because of intraoperative haemodynamic instability and impaired exposure of the dilated heart. Pre-emptive mechanical circulatory support may resolve these tensions. This video tutorial presents the Impella 5.5-supported coronary artery bypass procedure, as an application of the 'protected cardiac surgery' concept. During this procedure, a surgically implanted microaxial flow pump (Impella 5.5) enables complete off-pump revascularization. Patient selection, preoperative planning and the step-by-step procedure are detailed, and illustrated by a patient with an ejection fraction of 19%, severe left ventricular dilatation, viable myocardium and three-vessel disease. The Impella 5.5-supported coronary artery bypass procedure was performed successfully, with planned postoperative support maintained, and eventual awake explantation. Consequently, this video tutorial demonstrates the feasibility and reproducibility of the Impella 5.5-supported coronary artery bypass procedure, allowing the conduct of future prospective comparative studies to define its eventual role, and to establish how pre-emptive support may improve outcomes.
Radical thymectomy has withstood the test of time as the standard procedure for treating thymic masses. Minimally invasive thymectomy, especially when performed using a surgical robot, has resulted in superior oncological clearance from the ipsilateral to the contralateral phrenic nerves, while drastically reducing the morbidity associated with median sternotomy. There is sparse literature on how to perform this procedure using a modular robotic system, which is gaining popularity. Here, we present our technique of robotic radical thymectomy through a right thoracic approach using a modular surgical robot, the Hugo RAS system, with emphasis on port positions, OT set-up and surgical steps.
Thoracoscopic intercostal nerve cryoablation is increasingly used as an adjunct to the Nuss procedure for pectus excavatum to reduce postoperative pain, yet detailed stepwise descriptions remain limited. This video tutorial presents a practical, structured description of the operative technique with emphasis on reproducible procedural steps. The patient is placed supine with both arms elevated, and single lung ventilation is established, commencing with the left-sided procedure. Thoracoscopic access is obtained through small lateral ports, followed by carbon dioxide insufflation to improve visualization. The thoracoscope is introduced to identify the third to eighth intercostal spaces. A cryoprobe is inserted through a lateral intercostal access point and positioned directly onto the intercostal nerve along the inferior border of each rib. A palpation instrument is used to retract the lung and facilitate safe exposure of the target nerve. Once correct positioning is confirmed, a controlled freezing cycle is initiated to achieve targeted nerve ablation, after which complete thawing is ensured before probe repositioning. The process is repeated sequentially for each intercostal level. After completion of cryoablation, an adjunctive intercostal block may be administered, followed by reinflation of the lung under thoracoscopic visualization. After the left-sided procedure is completed, it may be reproduced on the right. Once the right-sided procedure is completed, standard Nuss bar placement is performed. Technical pitfalls related to probe positioning, rib level identification, and tissue protection are highlighted to support safe and consistent application of the technique.
Tracheal resection/reconstruction is among the most technically demanding procedures in thoracic surgery, traditionally requiring open approaches with complex airway management. The emergence of robotic-assisted surgery combined with venovenous extracorporeal membrane oxygenation (VV-ECMO) offers a minimally invasive alternative providing enhanced surgical precision, reduced postoperative morbidity and optimal apnoeic operative conditions. We report a robotic tracheal resection/reconstruction under VV-ECMO in a 65-year-old patient with a tracheal mucoepidermoid carcinoma following endoscopic debulking with incomplete margins. Key surgical highlights include a percutaneous VV-ECMO enabling complete apnoeic conditions, lymph node dissection to initiate progressive tracheal exposure, preserving the vagus nerve and tracheal vascularization, an original fluorescence-guided transillumination technique for intraoperative resection margin identification, and end-to-end anastomosis using three continuous V-Loc sutures. The patient was discharged on postoperative Day 7 with no major complications. Resection was finally complete, and anastomotic integrity was confirmed at two-month bronchoscopy. Given the rarity of this tumour and the steep learning curve of robotic airway surgery, a step-by-step video tutorial was necessary to establish a reproducible, didactic framework for this combined approach.
Resectional and non-resectional techniques are both well established in mitral valve repair. While we generally prefer resectional methods when feasible, neochordae represent an essential complementary tool to maximize repair rates. Herein, we present our adaptation for the robotic approach and highlight key principles for using neochordae to achieve durable repair.
Reintervention after truncus arteriosus repair is frequently driven by progressive neoaortic (truncal) valve regurgitation. In many patients, valve dysfunction is primarily associated with annular and root dilatation rather than intrinsic leaflet pathology. We present a 6-year-old child with prior neonatal repair of truncus arteriosus who developed severe truncal valve regurgitation in the setting of marked annular dilatation and quadricuspid truncal valve. The patient underwent truncal valve repair by tricuspidization, annular reduction and root stabilization. Replacement of the right pulmonary valve was performed. Postoperative echocardiography demonstrated excellent truncal valve function with only a trace of regurgitation. At 2-month follow-up, valve function remained stable. This case highlights the importance of annular reduction and valve-preserving strategies in truncal valve surgery.
Neoaortic valve repair after arterial switch operation can be challenging due to altered valve geometry and the absence of an ideal material for leaflet augmentation. We report repair of severe neoaortic valve regurgitation in a 22-month-old child using autologous pulmonary artery wall for cusp augmentation. A geometry-driven approach was applied, including augmentation of all cusps to increase coaptation surface and enlargement of the right sinus of Valsalva. This demonstrates feasibility of the neoaortic valve repair with autologous living pulmonary artery wall.
Extensive mitral annular calcification represents a major technical challenge in mitral valve surgery and is associated with increased operative mortality and morbidity, including atrioventricular disruption, circumflex artery injury and prosthetic valve dehiscence. Management strategies remain controversial, including in patients suitable for transcatheter interventions. We present a case of severe symptomatic mitral regurgitation in an elderly female patient with extensive circumferential mitral annular calcification. Preoperative imaging confirmed severe mitral regurgitation with restricted calcified mitral leaflets and preserved left ventricular systolic function. Transcatheter mitral valve implantation was considered, but deemed unsuitable because of annular size. The patient therefore underwent endoscopic mitral valve replacement through a right minithoracotomy using femoro-femoral cardiopulmonary bypass. An endoaortic balloon was used to arrest the heart with cardioplegia. After excision of the native valve and limited debridement of calcification, a bioprosthetic mitral valve was implanted and tied with pledgeted braided sutures and an automatic suture knotting device (CorKnot). A bovine pericardial patch was sutured to the posterior portion of the prosthetic sewing ring using a posterior skirt technique to reinforce the posterior annulus and reduce paravalvular leakage risk. Postoperative echocardiography demonstrated a well-functioning prosthetic valve with preserved ventricular function and a trivial paravalvular leak.
We present a case of an otherwise healthy young male with a 5.0 cm aortic root aneurysm complicated by a thin "sinking" right sinus of Valsalva who underwent a valve-sparing aortic root replacement with a planned right ventriculotomy.
We present the case of a young man with a prior homograft root replacement and a subsequent transcatheter aortic valve-in-valve, who presented with a root pseudoaneurysm and severe aortic regurgitation due to valve degeneration from endocarditis. The surgical procedure involved the explant of transcatheter aortic valve implantation prosthesis using a snare technique, removal of the homograft and a subannular Bentall procedure. This case illustrates the technical challenges and the "lifetime management" strategy required for complex redo aortic interventions in younger patients.
We report the case of a 52-year-old woman with severe tricuspid regurgitation due to Ebstein's anomaly. She underwent surgery through a 2.5 cm right minithoracotomy incision under three-dimensional endoscopic visualization. After identification of the atrialized right ventricle and the displaced attachments of the septal leaflet and part of the posterior leaflet within the atrialized segment, plication of the atrialized portion was performed to exclude it. The displaced leaflet attachment level within the atrialized right ventricle was regarded as the functional tricuspid annulus and served as the site for annuloplasty. Tricuspid annuloplasty was then performed using a semi-rigid partial ring, and leaflet coaptation was further improved by an edge-to-edge valvuloplasty. Postoperative echocardiography showed trace tricuspid regurgitation, and computed tomography demonstrated resolution of the atrialized right ventricle. She was discharged home in good condition.
A 7-year-old cyanotic child with unrepaired tetralogy of Fallot, a single coronary artery arising from the left coronary sinus, and suspected pulmonary thromboembolism underwent complete intracardiac repair. This video tutorial demonstrates a comprehensive surgical strategy that simultaneously addresses intracardiac repair and pulmonary thromboendarterectomy while safely managing a rare coronary anomaly. Following median sternotomy and establishment of cardiopulmonary bypass, the pulmonary arteries were carefully inspected because preoperative imaging suggested thrombotic material within the pulmonary artery. Pulmonary arteriotomy revealed organized thromboembolic material, which was meticulously removed, restoring pulmonary arterial patency. Attention was then directed to correction of the congenital cardiac defect. The large malaligned ventricular septal defect was closed with a polyester patch through the right atrial approach. Severe right ventricular outflow tract obstruction caused by infundibular and valvular pulmonary stenosis was relieved by extensive muscle resection and pulmonary valvotomy.
Minimally invasive surgery is the standard of care for lung resections in patients with early-stage non-small cell lung cancer. Non-intubated thoracic surgery, relying on spontaneous ventilation under sedation and locoregional anaesthesia, has emerged as an alternative to general anaesthesia with potential advantages for patients. The application of non-intubated thoracic surgery to video-assisted thoracic surgery to perform anatomical lung resections has already been described and aims at merging the benefits of the two techniques to improve the patient postoperative course. Robotic-assisted thoracic surgery represents a further refinement of minimally invasive techniques, offering several advantages over video-assisted thoracic surgery in complex procedures. To the best of our knowledge, this is the first case of a robotic-assisted lung segmentectomy performed without endotracheal intubation and under locoregional anaesthesia and sedation.
Herein, we described a redo tracheostomy in a patient with a large mediastinal goitre. A percutaneous dilation tracheostomy was performed under rigid bronchoscopy. Rigid bronchoscopy provided several advantages compared with flexible bronchoscopy. It suctioned significant blood and secretions, secured the airway and ensured adequate ventilation during the entire procedure. Technically, the rigid barrel displacing the trachea anteriorly facilitated the insertion of dilators and the tracheostomy cannula and reduced the risk of airway injury. This strategy was safe and feasible and could turn out to be useful in patients with difficult airways where standard percutaneous dilation tracheostomy is difficult to perform.
This video tutorial demonstrates a Damus-Kaye-Stansel procedure performed concomitantly with a bidirectional cavopulmonary shunt in a patient with a double inlet left ventricle, malposed great arteries, and a ventricular septal defect. Given the anteroposterior relationship of the great vessels, the DKS anastomosis was performed using a "double-barrel" technique with patch augmentation. Postoperative evaluation confirmed a widely patent systemic outflow tract and preserved semilunar valve integrity. The patient remains clinically stable at the 6-month follow-up.
We present a challenging case of truncus arteriosus type II repair in a 2-month-old, 3.3 kg infant admitted with heart failure and cyanosis. Right ventricular-to-pulmonary arterial continuity was restored using a right atrial free-wall autograft, while a neopulmonary valve was constructed from the right atrial appendage, providing an autologous valved connection. The patient also exhibited moderate-to-severe truncal valve stenosis and mild regurgitation, which were addressed with concomitant valve repair. The patient also had a single coronary artery.
Robotic-assisted thoracic surgery has become increasingly utilized for the management of lung cancer, particularly in technically demanding anatomical resections. The robotic platform provides enhanced depth perception, refined instrument articulation and improved precision. This facilitates complex pulmonary resections such as segmentectomies. This minimally invasive approach is increasingly favoured over open thoracotomy due to its association with reduced postoperative complications and accelerated recovery. Anatomical segmentectomy remains technically challenging due to variations in bronchovascular anatomy. The incorporation of three-dimensional reconstruction imaging enables detailed pre-operative assessment of tumour location and its relationship to surrounding structures, allowing for more precise and individualized surgical planning. Despite these advantages, the routine use of three-dimensional imaging in thoracic surgery is not yet widely established across thoracic surgery centres, and has limited exposure in the literature. This video atlas series presents a robotic-assisted anatomical segmentectomy guided by three-dimensional reconstruction. This tutorial provides a structured, step-by-step approach to performing a right S2 posterior segmentectomy for a patient with a right upper lobe tumour.
Sleeve lobectomy with bronchoplasty is a complex but lung-preserving operation, often requiring open thoracotomy. Robotic-assisted thoracoscopic surgery offers enhanced visualization and instrument dexterity, enabling such procedures to be performed with minimal invasiveness. We report a case of a 75-year-old man with squamous cell carcinoma located in the lingual segment of the left upper lobe, which invaded to the entrance of left upper lobe bronchus. The tumour was staged as cT2aN0M0. Due to its central location, robotic left upper sleeve lobectomy with bronchoplasty was selected. A five-port approach was used. Pulmonary vessels of the left upper lobe were dissected and divided using robotic staplers. After sleeve resection of the bronchus, bronchial reconstruction was performed using a continuous barbed suture, and the anastomosis was reinforced with a pericardial fat pad and fibrin sealant. The console time was 267 minutes with minimal blood loss. The chest tube was removed on postoperative Day 1, and the patient was discharged on Day 5 without complications. Pathology confirmed pT2aN0M0 squamous cell carcinoma with negative margins. Robotic left upper sleeve lobectomy with bronchoplasty is feasible and safe in selected patients, providing the advantages of minimally invasive surgery without compromising oncological outcomes.
Sleeve lobectomy with bronchoplasty is a complex yet lung-sparing procedure traditionally performed via open thoracotomy. Robotic-assisted thoracoscopic surgery, with enhanced visualization and instrument dexterity, may facilitate this technically demanding procedure in a minimally invasive setting. We report the case of an 85-year-old man with adenocarcinoma in the right upper lobe, accompanied by an isolated intrapulmonary metastasis and an enlarged lymph node #4R and #11s, with #11s invading the orifice of the right upper lobe bronchus. The clinical stage was cT3N2aM0 (stage IIIB). Because of bronchial involvement by metastatic lymph node #11s, robotic right upper sleeve lobectomy with bronchoplasty was performed. A five-port approach was used. The right upper lobe pulmonary vessels were individually dissected and divided using robotic staplers. After sleeve resection of the bronchus, bronchial reconstruction was completed with a continuous barbed suture. The anastomosis was reinforced with a free pericardial fat pad and fibrin sealant. Console time was 226 minutes, with minimal blood loss. The chest tube was removed on postoperative Day 1, and the patient was discharged on postoperative Day 5 without complications. Pathology confirmed pT3N2bM0 adenocarcinoma with negative margins. Robotic right upper sleeve lobectomy with bronchoplasty may be a feasible minimally invasive option in selected patients requiring complex airway reconstruction.
