Ask our Doctor: Is MICS safer than open-heart surgery?

Minimally invasive cardiac surgery (MICS) is an advanced surgical approach that allows certain heart procedures to be performed through small incisions between the ribs instead of opening the breastbone.

Although the technique has become increasingly common, many patients still have questions about how it works, who it is suitable for and how it compares with traditional heart surgery.

(Adj) Prof Theodoros Kofidis, cardiothoracic surgeon at Mount Elizabeth Hospital with deep experience in minimally invasive heart surgery, answers some of the most frequently asked questions about this surgical approach.

Is minimally invasive cardiac surgery safer than open-heart surgery?

Both minimally invasive and traditional open-heart surgery are established procedures with good outcomes when performed by experienced surgical teams.

For suitable patients, minimally invasive techniques may offer benefits such as:

• smaller incisions
• reduced surgical trauma
• less visible scarring
• less arrhythmias (irregular heartbeat)
• less bleeding
• better early postoperative lung function
• shorter hospital stays
• faster recovery
• faster and better mobility

However, safety ultimately depends on selecting the right surgical approach for each individual patient and condition.

How is minimally invasive cardiac surgery different from traditional open-heart surgery?

Traditional open-heart surgery usually involves a median sternotomy, where the breastbone is divided to provide full access to the heart.

In minimally invasive cardiac surgery, the surgeon operates through smaller incisions between the ribs, typically on the side of the chest. Specialised instruments and imaging technology allow surgeons to perform complex repairs through these smaller openings.

While the surgical access is different, the goal of the operation – repairing or treating the underlying heart condition – remains the same.

What heart conditions can be treated with minimally invasive cardiac surgery?

Minimally invasive techniques may be used for a range of cardiac procedures, including:

• mitral valve repair or replacement
• tricuspid valve surgery
• certain coronary artery bypass procedures
• closure of some congenital heart defects
• removal of selected cardiac tumours

The suitability of minimally invasive surgery depends on factors such as the patient’s anatomy, the complexity of the condition and overall health.

Who is a suitable candidate for minimally invasive heart surgery?

Many patients with valve disease or certain coronary artery conditions may be suitable candidates.

However, not everyone will benefit from minimally invasive approaches. Patients with complex heart disease, extensive coronary artery disease or previous chest surgeries may require conventional open-heart surgery.

Your surgeon will evaluate imaging scans, medical history and overall risk factors before recommending the most appropriate approach.

What tests are required before minimally invasive heart surgery?

Before surgery, doctors perform several tests to understand the heart condition in detail and determine the best surgical approach.

Common preoperative tests may include:

• echocardiography to evaluate heart valve function and blood flow
• CT scans to assess chest anatomy and blood vessels
• coronary angiography to check for coronary artery disease
• electrocardiograms (ECG) to assess heart rhythm
• blood tests to evaluate overall health

These assessments help surgeons plan the procedure and ensure that minimally invasive techniques are suitable for the patient.

How do surgeons see and operate inside the chest through small incisions?

Minimally invasive cardiac surgery relies on a combination of advanced technologies, including:

• high-definition surgical cameras
• specialised long instruments
• three-dimensional imaging
• precision surgical retractors

These tools allow surgeons to visualise the heart in great detail while operating through small openings between the ribs.

Is robotic heart surgery the same as minimally invasive cardiac surgery?

Robotic cardiac surgery is a specialised form of minimally invasive cardiac surgery.

In robotic-assisted procedures, the surgeon controls robotic instruments that translate the surgeon’s hand movements into extremely precise movements inside the chest.

However, not all minimally invasive procedures require robotic assistance. Many operations can be performed using specialised instruments and cameras through small incisions.

The choice of technique depends on the type of heart condition being treated and the surgeon’s clinical judgement.

How long does minimally invasive heart surgery take?

The duration of surgery depends on the specific procedure being performed.

Many minimally invasive cardiac operations take several hours, similar to traditional heart surgery. The difference lies primarily in how the surgeon accesses the heart rather than the complexity of the repair itself.

Does minimally invasive heart surgery last as long as traditional surgery?

For many procedures, particularly mitral valve repair, long-term outcomes of minimally invasive cardiac surgery are comparable to traditional open-heart surgery when performed in experienced hands.

The durability of the repair or treatment depends more on:

• the underlying heart condition
• the complexity of the repair
• the surgeon’s expertise

rather than the size of the incision used to access the heart.

How long does it take to recover after minimally invasive heart surgery?

Recovery times vary between patients, but many people experience a faster return to daily activities compared with traditional open-heart surgery.

Because the breastbone is not divided, patients may be able to resume certain activities earlier, although full recovery still requires time and careful follow-up with the surgical team.

Will I have a scar after minimally invasive heart surgery?

Minimally invasive cardiac surgery usually involves smaller incisions between the ribs, often measuring only a few centimetres.

These scars are typically less noticeable than the long incision used in traditional open-heart surgery.

Does minimally invasive heart surgery reduce the risk of complications?

For suitable patients, minimally invasive approaches may help reduce certain risks associated with surgery, such as:

• wound complications
• infection
• bleeding
• prolonged hospital stay

However, every heart operation carries potential risks, and outcomes depend on multiple factors including the patient’s overall health and the complexity of the procedure.

Can minimally invasive heart surgery be repeated if needed later?

In many cases, yes. If further treatment is required in the future, additional surgery may still be possible.

However, the choice of surgical approach depends on several factors, including:

• the patient’s current heart condition
• the type of previous surgery performed
• scar tissue or anatomical changes from earlier procedures

Your cardiac surgeon will evaluate imaging studies and your overall health to determine the safest approach if another operation is required.

Can patients with previous heart surgery still undergo minimally invasive cardiac surgery?

Some patients who have previously undergone heart surgery may still be candidates for minimally invasive procedures.

However, previous operations can sometimes lead to scar tissue around the heart and chest structures, which may make certain minimally invasive approaches more technically challenging.

Before recommending surgery, doctors will carefully review imaging tests and medical history to determine whether a minimally invasive approach remains appropriate or whether conventional surgery would provide better access and safety.

How important is surgeon experience in minimally invasive cardiac surgery?

Minimally invasive cardiac surgery is technically demanding and requires specialised training and experience.

Successful outcomes depend on several factors, including:

• careful patient selection
• surgical expertise
• specialised operating teams and equipment

Hospitals and centres with dedicated experience in minimally invasive techniques often have teams that routinely perform these procedures and are familiar with managing their specific technical challenges.

Patients considering surgery may wish to discuss their surgeon’s experience with minimally invasive procedures as part of the decision-making process.