Beyond the Book: Continuous Evolution in Minimally-Invasive Coronary Surgery

The concepts and operative techniques presented in our book Minimally-Invasive Coronary Artery Bypass Surgery (Albert A., Angleitner P., Springer, 2026) are built on principles that have been developed, refined, and validated over several decades. This applies particularly to the fundamental concepts of off-pump coronary artery bypass surgery (OPCAB) and arterial revascularization, which are deeply rooted in the principles and techniques developed and taught by Paul Sergeant.

Over more than two decades, the essential principles of this surgical approach have changed remarkably little. What has evolved, however, is the increasing individualization of revascularization strategies according to coronary anatomy, the severity and distribution of coronary disease, and individual patient characteristics.

The classical strategy taught within the Sergeant school is based on anaortic, clampless OPCAB and predominantly arterial grafting, typically using a single inflow from the left internal thoracic artery (LITA), with the right internal thoracic artery (RITA) as a composite graft to the lateral and inferior walls. While the fundamental off-pump techniques have proven to be highly stable, reproducible, and robust across different institutions, surgical teams, and individual surgeons, graft configurations and revascularization strategies have become increasingly individualized.

The field of minimally-invasive coronary surgery, in contrast, continues to undergo substantial technical refinement and evolution. In our program, we use a direct-vision approach for both conventional single-vessel minimally-invasive direct coronary artery bypass (MIDCAB) and more complex multivessel MIDCAB procedures. Based on our growing experience with the routine application of these techniques, several important trends are emerging.

One is the increasingly frequent use of the right internal thoracic artery, reducing our reliance on the radial artery as a composite T-graft, which is emphasized more prominently in the book. Another development is the almost complete avoidance of proximal aortic anastomoses. We are also increasingly using the RITA in situ as a second independent inflow, with an I-graft extension using the radial artery when additional length is required. This double-inflow concept provides further flexibility for complete arterial revascularization.

The routine use of the RITA through a minimally-invasive access has been facilitated by relatively small but important technical modifications, including improved instruments for lung retraction and longer electrocautery devices. Such developments illustrate an important reality of minimally-invasive coronary surgery: while the underlying surgical principles remain constant, the techniques used to implement them continue to evolve.

This section of the website is intended to accompany the book and provide a platform for precisely these ongoing developments. The book remains the comprehensive foundation, presenting the concepts, strategies, and operative steps in a structured and multimodal format. Here, readers will find updates, technical refinements, new operative strategies, and lessons derived from our continuously growing clinical experience.

Our long-term vision is complete arterial coronary revascularization with the least possible surgical trauma—allowing patients to recover rapidly, experience minimal postoperative pain, and return home within only a few days. Experience with endoscopic and robotic MIDCAB procedures has already demonstrated how close coronary surgery can come to this goal.

We consider our direct-vision technique an important step along this pathway. By avoiding sternotomy while maintaining the flexibility to perform complex multivessel and complete arterial revascularization, it combines the established principles of anaortic OPCAB surgery with a substantially less invasive surgical access.

Current robotic and totally endoscopic coronary programs remain largely focused on revascularization of the anterior and anterolateral coronary territories. In our view, the next major step should be to extend these approaches toward complete minimally-invasive arterial revascularization.

We therefore see the future not exclusively in hybrid revascularization, but also in the convergence of techniques: combining the completeness and flexibility of the multivessel direct-vision approach with the progressively reduced surgical trauma offered by endoscopic and robotic technologies.

At present, however, fully endoscopic and robotic coronary surgery remains limited to a relatively small number of specialized centers. We therefore believe that becoming familiar with direct-vision, minimally-invasive off-pump coronary surgery represents a practical and important pathway for cardiac surgeons and institutions seeking to develop a comprehensive minimally-invasive coronary program.

In this Book Update, we invite you to follow these developments as they evolve—from technical modifications and new graft configurations to our continuing pursuit of complete, anaortic, total arterial revascularization through the least invasive approach possible.