Totally endoscopic mitral valve repair without robotic assistance: A case report

•Robotic TEMVR is the most advanced level of MICS.•We have performed TEMVR using no robotic system.•The used equipment included MICS instruments and a 3D Endoscopic system.•We improved mitral valve exposure techniques and surgical port placement.•We used sutures as a left atrial retractor to expose mitral valve. Totally endoscopic mitral valve repair (TEMVR) is the highest level of minimally invasive cardiac surgery (MICS). It brings many benefits to patients but the downside is that a robotic system is always required. The deployment of robotic surgery is very complicated and expensive. Therefore, we improvised, making it possible to perform TEMVR without the aid of a robotic system. A 66-year-old male patient presented with severe mitral valve regurgitation due to posterior leaflet prolapse. He was treated with TEMVR without robotic assistance. No chest incision was over 1.2 cm. The repair techniques included posterior leaflet resection and annuloplasty with ring implantation. A midline sternotomy is still the standard approach for mitral valve repair. In recent years, MICS has gradually replaced conventional surgery with the most advanced strategy being totally robotic mitral valve repair. However, complex surgical techniques and high cost make it less accessible for the majority of patients. Instead of using robot, we improved mitral valve exposure techniques, surgical port placement and therefore were able to perform TEMVR with MICS instruments. TEMVR without robotic assistance is a safe, effective and cost-efficient procedure, which can be adopted in most cardiac centers.