Arterial valve disease is one of the most common adult heart diseases in China. There are many causes of the disease. Whether it is a congenital valvular malformation, rheumatic disease, degenerative valve disease or infective endocarditis, it will reduce the function of left ventricular outflow tract, cause hemodynamic changes and increase the load of left and right ventricles [
10]. In addition, with the progress of the disease, patients gradually have obvious symptoms of heart failure and other complications, which seriously threaten the life and quality of life of patients [
11‐
13]. In the past 20 years, minimally invasive cardiac surgery (MICs) has developed by leaps and bounds and has been widely used all over the world [
14]. It is different from the classic cardiac surgery in the past 50 years (such as median thoracotomy, longitudinal splitting of sternum for extracardiac surgery or heart valve surgery with cardiopulmonary bypass) [
15]. AVR can be completed through a conventional median sternotomy with low morbidity, relatively low cost, and an excellent long-term result. However, the long incision in the median of the chest makes patients reluctant to undergo the conventional AVR [
16,
17]. Also, it may result in bleeding, infection, and extended hospital stay. Furthermore, the incision leaves an unpleasant scar, which could be a source of persistent psychological problems and dissatisfaction. Because there is a very close relationship between body image and self-esteem, Michal and others insist that scars caused by heart surgery may have a considerable impact on the patient's body image and several aspects of daily life [
18]. Our results tend to support this view. However, small incisions or various special surgical instruments are used for some heart surgery. One of the technical cores is to reduce or reduce the physical and mental trauma of the patient by reducing the surgical incision on the premise of ensuring the safety of the patient's operation. Previous studies have reported the feasibility of some cardiac procedures using robotic surgical systems, including mitral valve repair or replacement, coronary artery bypass grafting, repair of atrial septal defects (ASD) and partial anomalous pulmonary venous connections (PAPVC) [
19‐
21]. With less blood loss, fewer incisions, and shorter hospital admissions, robotic cardiac surgery has proved to be a progressive technique [
22].
Although reports have proved the effectiveness and safety of robot assisted cardiac surgery, it has not become the standard of care for the treatment of heart diseases. Through the efforts in our institution, we successfully operated four cases of totally endoscopic robotic AVR. Although reports have proved the effectiveness and safety of robot assisted cardiac surgery, it has not become the standard of care for the treatment of heart diseases. We used bicaval cannulation and an opening of the right atrium for direct insertion of a coronary sinus catheter in our surgery and the reasons are as follows: first, the opening of part of the coronary vein in the coronary sinus may be blocked after the water bag is used, causing the cold perfusion to not evenly enter the coronary vein. Second, considering that the blocking time may be longer, a more reliable myocardial protection solution perfusion is required to achieve a good myocardial protection effect.
The disadvantages of totally endoscopic robotic AVR include: (1) the lack of complete hook results in some trouble when exposing the aortic valve; (2) too much time was spent on knotting; (3) It is difficult for assistants to co-operate; (4) cold blood cardioplegia retrograde was delivered through the coronary sinus; (5) putting sutures in the annulus requires consummate surgical technique. Above all, we consider that the procedure of totally endoscopic robotic AVR is complex and time-consuming. Totally endoscopic surgery in other fields has shown improved quality of life but with longer clamping and CPB times during the learning curve [
23,
24]. Though the clamping and CPB times were a little long for the complex operation and knotting in our cases, we believe they could be shorter with more practice. Furthermore, we believe that practice on animal tissues such as pig hearts before going clinically could help decrease risks. Also, inadequate instruments may result in difficulties and inconvenience, which may lead to more time consumption. Therefore, in the future, we think it is necessary to research some dedicated instruments for different robotic cardiac surgery and realize the specialization of surgical instruments.