Background-The introduction of robotic enhanced surgery demanded stepwise development of performed procedures on the basis of growing experience of the operating team. Methods and Results-Between May 1999 and January 2001, this new wrist-enhanced instrumentation was used in 201 patients (156 men and 45 women, median age 64Ϯ10.5 years, left ventricular ejection fraction 68Ϯ12.4%). During the development of robotic enhanced CABG, the patients were divided into 3 groups. Group A (nϭ156) consisted

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... f patients in whom the robotic system was used to harvesting the left or right internal mammary artery, or both, whereas the anastomoses were performed directly through a small chest incision. In group B (nϭ37), the harvest of the internal mammary arteries and the coronary anastomoses were performed totally endoscopically. In a third early group C, patient (nϭ8) were treated with robotic enhanced CABG via a median sternotomy already preoperatively planned, whereas gradual step-by-step application of robotic instrumentation and its feasibility were assessed. The survival rate was 99.4%. One patient (0.6%) died due to pneumonia on postoperative day 16. Conversion rate to median sternotomy was 5%. The left and right internal mammary artery conduits could be successfully harvested in 98% and 100%, respectively. The time of dissection of the left internal mammary artery could be significantly reduced alone by increasing experience. All patients were discharged from the hospital after a mean of 7 days. In 9 patients (4.5%), bleeding required reexploration. Conclusions-The introduction of this new surgical tool enables the development of new endoscopic procedures. Our results gained during the development of robotic enhanced CABG motivate us to establish a set standard for the totally endoscopic treatment of patients with 1-vessel coronary artery disease. (Circulation. 2001;104[suppl I]:I-102-I-107.)