الفهرس 
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Abstract
Since the mid-1990s, cardiac surgery has shown a progressive and increasing interest towards the development of minimal invasive and minimal access techniques virtually worldwide.
In almost a decade, minimal access and robotic techniques have been originally described and subsequently redefined following the design of facilitating new tools and technologies and have now become established and perfectly reproducible surgical procedures.
Significantly demanding learning curves for the team and technical challenges for the operating surgeons are commonly required. Training options are available and surgical mentoring has surely become the most modern way to safely export technical knowledge and experience of new techniques to other teams in a clinical governance-based health care.
The total number of minimal access procedures (MICS) performed annually in each country represent an unfair target measure of the actual progress achieved since the 1990s in cardiac surgery given that MICS adoption remains limited to a small group of surgeons. The traditional cardiac surgical community remains concerned about the need of time-consuming and often technically demanding additional training, the increased intra-operative costs and continues practicing in a more than ever litigious society. A better picture of the present status of MICS is surely given by the presence of ‘totally converted off pump’ surgeon or surgeons who regularly perform their nearly entire annual case loads of isolated aortic and mitral valve procedures via a minimal access route. In the UK only, the percentage of ‘off pump’ coronary operation have reached a plateau of about 16% in the years 2001-008, but in real terms, this represents not part but the entire coronary revascularization work load for a small group of skilful cardiac surgeons.
Our effort in redeveloping ourselves by approaching new technological tools and learning new techniques has to be weighed against the reality that referral pr practices in cardiac surgery are constantly changing and are also influenced by the presence of several different therapeutic percutaneous approaches offered by interventional cardiologists who are ultimately in competition with us for the treatment of the same patients.
Ongoing research and development will surely offer cardiac surgeons novel tools to more easily apprenticeship robotic and minimal access techniques. ‘Tissue deformation tracking’ is one of the exciting technologies under investigation, and it combines tracking of reference points based on stereo-thoracoscopic images and constrain edge ometrical surface model that deforms with heart motion. The definition and introduction in clinical practice of similar technologies is likely to slowly return to cardiac surgeons that safety net that is lost in the large gap existing between the performances of traditional versus totally endoscopic operation at present.
As for the future, minimally invasive cardiac surgery is likely to become more widely adopted as growth in this niche market and cardiac surgery as a whole is often patient-driven, much in the same way that percutaneous intervention for multivessel disease has been. In essence, patients do not want a sternotomy and it is important as a surgical community that we realize this. However, despite enthusiasm, caution cannot be overemphasized as traditional cardiac operations still enjoy proven long-term success and ever-decreasing morbidity and mortality and remain our benchmark measures for comparison. To pave the path towards totally endoscopic valve surgery, surgeons, cardiologists, and engineers must focus on improving the methods of computerization of the instruments.