Minimally Invasive Cardiac Surgery - Endoscopic Heart Surgery

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Find out whether your operation can be done through a small incision

Not every heart operation suits this route, and the honest answer depends on your anatomy rather than on your preference. Send the echocardiogram with its moving images, any cardiac CT or angiogram, a recent chest scan, your medication list and a note of any previous chest surgery or radiotherapy. A cardiac surgeon reviews the file and tells you which approaches are open to you, which one would be recommended and why, and what the smaller incision would and would not change. No fee, no obligation, and a coordinator answers in your own language.

What the words cover

Minimally invasive cardiac surgery is not one operation. It is a label covering every route into the heart that avoids splitting the breastbone from top to bottom, and the routes differ from one another more than most patient pages admit. A clinic that says only that it does minimally invasive surgery has told you nothing. Ask which route.

Five terms account for nearly everything you will read.

• Ministernotomy. The breastbone is divided along part of its length instead of all of it, which for an aortic valve means the upper half. The bone still has to heal, so the lifting restrictions stay, but less of it is cut.
• Right minithoracotomy. A short incision between the ribs on the right side of the chest, with a camera for light and magnification. The breastbone is untouched. That is the point.
• Totally endoscopic surgery. The same right-side route taken further, with the work done entirely through ports while the surgeon watches a screen. No incision is wide enough to look through.
• Robotic surgery. A totally endoscopic operation in which the instruments are held by robotic arms the surgeon drives from a console a few feet away. The robot decides nothing. No machine is operating on you, and a surgeon who lets that impression stand is doing you a disservice.
• Minimally invasive coronary bypass. A bypass graft placed through a small left-side incision, on a beating heart, without the bypass machine. This one applies to blocked arteries and not to valves, so it belongs in a different conversation from the four above.

Endoscopic heart surgery means the third and fourth of those. Ask which term applies to the operation being offered to you and write the answer down, because the recovery, the restrictions, the risks and every one of the numbers further down this page read differently depending on which of the five you are actually being offered.

The four ways in

No route reaches everything. Each one reaches a different part of the heart comfortably and leaves the rest of it awkward, which is why the incision follows the diagnosis instead of the other way round. The right side of the chest gives an excellent view of the mitral and tricuspid valves and a poor one of the coronary arteries, while the upper breastbone gives a clean view of the aortic valve and very little else. Where a surgeon cuts follows from which valve is being operated on, so the choice is largely made for you by your own diagnosis.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

One practical consequence of the right-side routes deserves early mention. The heart-lung machine connects through the vessels in the groin instead of through the chest, which leaves a short wound at the top of the leg, carries a low risk of injury to the vessel itself, and carries a low risk of poor circulation to that leg afterwards. In most cases it is a minor point. In a patient with significant disease in the leg arteries it is decisive, and that is why those arteries are scanned with a CT before anybody promises you a small incision, rather than discovered to be unusable once you are already asleep on the table.

What the trials found

Two randomized trials have asked the question properly, one for the mitral valve and one for the aortic valve, and neither of them produced the answer the marketing implies, which is the single most useful thing a patient can know before sitting down with a surgeon to choose an incision. Both are worth reading about. A third body of evidence, much larger but observational, points somewhere friendlier, and understanding why the two disagree is most of what a patient needs from this page.

Why the disagreement. Observational studies compare patients who were chosen for a small incision against patients who were not, and the choosing is the problem, because a surgeon offers this route to the fitter, thinner, younger, less calcified patient with better lungs and no previous chest surgery. Those patients would have done better through any incision. Randomization removes exactly that advantage, which is why the mortality benefit shrinks toward nothing whenever a trial is run properly. What the mitral trial found beyond its headline deserves its own paragraph. A null primary outcome is not a null trial. Patients randomized to the small incision left hospital sooner and needed less blood, exactly as the observational literature had predicted. The physical function score at twelve weeks did not capture any of it. That is partly because the measure is coarse, and partly because by twelve weeks most patients in both groups had already got back to whatever they were going to get back to, which is exactly the sort of ceiling that hides a real early difference. A trial can therefore be entirely honest and still tell you less than you wanted, and the sensible reading is that the small incision improves the first month rather than the first year. The trial's economic analysis added a finding that patients rarely see and hospitals argue about constantly. The minimally invasive operation cost more and delivered slightly more quality-adjusted life, and the ratio between those two came out well above the threshold health systems normally use to fund a treatment. That is an argument about how a public system spends its budget and not an argument about whether the operation is good for you, but it does explain why the approach is offered enthusiastically in some countries and rationed in others.

Where the advantage is real

None of that makes the small incision pointless, and reading the evidence as a verdict against it would be a mistake. What it does is move the benefits from the column patients assume to the column that actually holds them. Blood is the clearest of them, and the easiest to verify. Across every kind of analysis, fewer patients need a transfusion and those who do need less, which matters to anybody who would rather not receive blood at all and matters medically because transfusion carries its own small risks. A large propensity-matched comparison of robotic and conventional mitral repair in patients over sixty-five found transfusion in 21 percent against 32 percent, and atrial fibrillation after surgery in 33 percent against 44 percent, which is a meaningful difference in a common and unpleasant complication. The same comparison found intensive care shortened by a few hours and hospital stay by a day, with no difference in long-term survival and none in the need for a further valve procedure.

Then there is the breastbone itself. A patient who keeps an intact sternum avoids the small but serious risk of a bone infection or a bone that fails to knit, and avoids the six weeks in which a divided breastbone forbids lifting, forbids pushing up out of a chair with the arms and forbids driving. For somebody who lives alone, cares for a small child, or works with their hands, that restriction is the single thing they most want to escape, and escaping it is a genuine benefit even though it does not show up in a physical function score at twelve weeks. The scar comes last, and it is the least medical item on the list. A right-side incision sits below the breast fold and disappears in most clothing, while ports leave marks the size of a coin. Wanting that is a legitimate reason to prefer this route. It is not a reason to accept it from a surgeon who does two a year, because the technique in unpractised hands gives back in longer bypass time and higher conversion rates everything the smaller incision was supposed to have won you.

The day itself

A right-side valve operation runs differently from the version most people picture. Knowing the sequence removes a good deal of the fear.

The trade you are making

Every account of this surgery worth reading names the cost. The cost is time. Working through a small opening with long instruments takes longer than working through an open chest, which means the heart is stopped for longer and the bypass machine runs for longer. In the pooled comparison of robotic against conventional mitral surgery the clamp time was about half an hour longer and the bypass time about fifty minutes longer.

You are trading time on the bypass machine for an intact breastbone. In a fit patient with good lungs and clean arteries that is a trade worth making. In a patient whose margins are already thin, the extra time is exactly what they cannot afford.

That sentence explains most of the candidacy rules further down this page. It also explains why volume matters so much here, since the extra time shrinks with experience while the benefits do not, and the authors of the robotic review said plainly that their own comparative evidence was of low quality. So the useful question is not whether a hospital offers minimally invasive cardiac surgery. Ask instead how many of your particular operation, by your particular route, the named surgeon performed in the last twelve months, and treat a vague answer as an answer.

Which operations qualify

The list has grown. It is longer than it was ten years ago and shorter than some websites imply, and the operations below are the ones done routinely through a small incision in units that do this work every week rather than occasionally. These are the operations routinely done through a small incision in units that do this work regularly.

• Mitral valve repair and replacement. The strongest indication and the one with the best evidence behind it, because the right-side view of this valve is genuinely superior to the view through an open chest.
• Tricuspid valve repair and replacement. Reached through the same incision, and routinely done in the same sitting as a mitral procedure without any additional cutting.
• Aortic valve replacement. Usually through an upper ministernotomy, sometimes through a small incision between the ribs on the right, and generally not through ports.
• Atrial septal defect closure. A hole between the upper chambers, closed through the same right-side route, and one of the operations where a young patient benefits most from keeping the breastbone intact.
• Maze procedure for atrial fibrillation. Added to a valve operation through the same opening, or occasionally done on its own to treat a rhythm that has resisted everything else.
• Removal of a heart tumor. Most often a myxoma in the left atrium, which sits exactly where a right-side camera looks.
• Single-vessel coronary bypass. A graft to the front of the heart through a small left-side incision, on a beating heart, for a patient whose disease is limited to that one artery.

Redo surgery deserves a separate mention, because it is the situation where opinion has shifted most. A patient who already has a divided and scarred breastbone faces real danger when it is opened a second time, and going in through the ribs avoids that scar entirely. Pooled data from redo mitral operations show a clear advantage for the non-sternotomy route in exactly this group, which is close to the opposite of the pattern in first-time surgery. If you have had heart surgery before, this route is worth asking about specifically.

When the answer is no

A surgeon who never says no is not being generous with you. The conditions below either make the small incision dangerous or make it pointless. A unit that screens for them properly is a unit whose published results are worth believing. Severe disease in the arteries of the abdomen or legs rules out the groin connection that most right-side operations depend on, so those vessels are scanned before anything is promised. Heavy calcium in the main artery leaving the heart does the same. Clamping a calcified aorta through a small opening risks dislodging debris toward the brain, and that risk is not worth a smaller scar. Lungs that cannot tolerate being deflated on one side rule the approach out on their own, which is why breathing tests come before the surgical decision and not after it. Previous surgery or radiotherapy on the right side of the chest leaves scarring that can make the space unusable, and severe deformity of the chest wall can do the same.

Coronary disease needing more than one graft is a different kind of no. There is nothing unsafe about it, but the arteries at the back and side of the heart cannot be reached properly through these routes, so an operation that would be complete through an open chest becomes incomplete through a small one. Accepting a lesser operation to get a smaller scar is the one trade nobody should make. A last group is harder to define and just as important. Emergency surgery, active infection destroying a valve, a very weak heart muscle and significant lung hypertension all shrink the margin a patient has, and the extra time on the bypass machine eats into precisely that margin. In those cases the right answer is a conventional sternotomy, done quickly and done well.

A final point belongs in every consent conversation. A small incision can become a sternotomy during the operation, for bleeding that cannot be controlled through the small opening, for a repair that will not hold, or for an anatomy that turns out to be different from the scans. It is uncommon. It is not a failure. Ask what the conversion rate is in the unit treating you, and treat a surgeon who claims never to have converted with more suspicion than one who tells you the number.

What can go wrong

Most of the risks here are the risks of any heart operation. Four of them belong to this approach in particular, and those are the four to ask about.

1. Trouble at the groin. The vessels used for the bypass machine can narrow, leak or clot, and the wound there can become infected or collect fluid. It is checked before you leave hospital and it is the reason you are asked about pain, numbness or coldness in that leg afterwards.
2. Stroke. The pooled data do not show more strokes with these routes overall, and the mechanism is different, since blood is being returned up the aorta rather than down it. Careful screening of the aorta and the neck arteries is what keeps that risk where it belongs.
3. Lung problems on the collapsed side. The right lung is deflated for the whole operation and does not always come back easily, particularly in a smoker. Breathing exercises started the same day and physiotherapy on the ward are the treatment, and both work better when you have practiced them beforehand.
4. Longer time on the bypass machine. Discussed above, and it is the risk that turns into other risks in a patient with limited reserve, as kidney injury or a slower recovery of the heart muscle in the first days.
5. Bleeding and conversion. Bleeding that cannot be reached through a small opening is the commonest reason for changing to a sternotomy partway through. It is handled the same way it would be handled anyway, with the incision made larger.
6. Rhythm disturbance. Atrial fibrillation after any valve surgery is common, and the matched data suggest it is somewhat less common after a robotic mitral repair than after a sternotomy. Drugs restore the rhythm in most patients and a brief shock under sedation settles the rest.
7. Rib pain that outlasts the wound. Working between two ribs irritates the nerve that runs under each one, and a minority of patients have a burning or aching band along that line for months. It fades in the great majority of patients over a few months, and drugs used for nerve pain help the minority in whom it does not. Of everything on this list, this is the complaint patients most often say nobody warned them about. Raise it before the operation.

Recovery and flying home

In hospital

Four to seven days for most people, which is roughly two days shorter than the same operation through an open chest. The breathing tube comes out within a few hours, the drains follow over the next day or two, and walking starts the morning after surgery. Pain between the ribs is sharper on deep breaths than breastbone pain is, so the nerve block placed during the operation and a proper schedule of tablets afterwards matter more here than patients expect.

At home

Two to four weeks to feel like yourself, against six to twelve after a full sternotomy, and this is the stretch of the recovery where an intact breastbone earns everything it promised, because the limits on what you can do with your arms are the limits most patients actually feel. There is no lifting restriction imposed by a healing bone, so you can push up out of a chair with your arms, carry a shopping bag and pick up a small child once the wound is comfortable. Driving is cleared at around two weeks instead of six, subject to the same rule everywhere, which is that you must be able to perform an emergency stop without hesitating. Desk work resumes at three to four weeks for most people. Ask about cardiac rehabilitation before you leave. Supervised exercise after heart surgery does more for your recovery than any instruction on this page, and a program you can join at home is easier to arrange while the hospital is still writing your paperwork than three weeks after you have landed.

Flying

Ten to fourteen days after a right-side incision and two to three weeks after a ministernotomy, on condition that the wounds are dry, the rhythm is stable, no fluid has collected around the operated lung and any blood thinning is settled. A doctor examines you before that date is written down, and the chest scan taken before it is the one that matters most, because a small collection of fluid around the lung that was deflated during surgery is common, usually harmless, and occasionally the reason a flight is postponed by a week. Take an aisle seat, walk every hour of the flight, and wear compression stockings unless you have been told otherwise.

Reading a quote

No figure appears on this page. A figure quoted before anybody has seen your scans is a marketing number, produced by someone who does not yet know which operation you need, which route it would be done by, or how many nights of monitored care your condition is going to ask for. What this surgery costs depends on which operation is being done, which route it is done by, whether a prosthesis is used and how many nights of monitored care your own condition is expected to need. Six questions turn a headline number into a real one. Which operation and which access route the quote assumes, since a robotic mitral repair and a ministernotomy aortic replacement are different products. What happens financially if the surgeon has to convert to a sternotomy partway through, which is the question almost nobody asks and the one that protects you best. Whether the prosthesis or annuloplasty ring is included and whether the price changes with the type chosen. How many intensive care nights are budgeted and what an additional one costs. Whether the work-up sits inside the number, meaning the coronary angiogram, the CT of the aorta and leg vessels, and the lung function tests that decide whether the small incision is possible at all. And whether the follow-up scan and the discharge paperwork before your flight are covered.

Your own condition moves the number as much as the technique does. Reduced heart muscle function, kidney disease, previous cardiac surgery, lung disease and any second procedure planned on the same bypass run each lengthen the expected stay in their own right, and several of them together lengthen it considerably. Packages published by Turkish hospitals and medical travel agencies for cardiac surgery generally include the airport transfer, pre-operative testing, surgeon, anesthesia and perfusion fees, the theater, the planned intensive care and ward nights, the implant, an interpreter and the review before departure. They generally exclude flights, insurance, unplanned additional intensive care, treatment of a complication and hotel nights beyond an agreed number. Read what arrives against that list first.

Send the file and wait for a written answer. The number that comes back will be about your operation rather than about an average one.

Coming to Istanbul

Plan on three weeks. Consultation and the tests that decide the route take the first few days, hospital covers four to seven, and the balance is hotel recovery before the flight home is cleared. Send more than the echocardiogram. Because the access route depends on your blood vessels and your lungs as much as on your valve, a CT covering the chest, abdomen and leg arteries and a recent set of breathing tests let a surgeon commit to an approach instead of hedging. Mention any previous operation or radiotherapy on the right side of the chest in your first message, since that single fact can change the whole plan. One coordinator carries your case from the first message to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages interpreted on request. Two things belong in the consent conversation on this page in particular, and both should be settled before you sign anything. The first is which access route is planned. The second is what happens if that route has to be abandoned partway through the operation, whether because of bleeding that cannot be reached, scarring nobody expected, or an anatomy that turns out on the day to differ from what the scans showed.

Somebody can stay with you overnight on the ward, where the rooms have a second bed, while intensive care follows that unit's own visiting rules. The international patients office books accommodation for both of you around the admission and arranges the airport transfer and daily hospital transport. Meals from the hospital kitchen cover halal, vegetarian and diabetic diets, a prayer room is available, and a request for a female physician in your first message lets the department plan for it. The same office prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, usually about ten days before travel.

Ask for a proper discharge file. A one-page summary is not enough. It should name the operation and the access route used, record any implant with its model and size, carry the echocardiogram findings from before you left, set out the medication plan including any blood thinning with its target range and next test date, and state when the wounds should be reviewed. Address it to a cardiologist and book that first appointment before you fly, while the hospital can still write the referral, because the weeks once you are back home are when the drug doses settle and the exercise builds. Your coordinator stays reachable on the same WhatsApp number, so a photograph of a wound or a question about a symptom reaches somebody holding your notes. Report a wound that reddens or discharges, a fever without an obvious cause, breathlessness that is getting worse, an irregular pulse, or pain, numbness or coldness in the leg used for the bypass machine.

Minimally invasive cardiac surgery FAQ