Clipless robotic LIMA harvesting: monitoring performance and safety through CUSUM and RA-CUSUM analyses.

BACKGROUND: The left internal mammary artery (LIMA) remains the conduit of choice for coronary artery bypass grafting (CABG). Robotic harvesting has become a growing frontier in cardiac surgical innovation, and therefore optimizing and simplifying the technique is of significant surgical importance. In this study, we present our experience with a clipless robotic LIMA harvesting strategy (cl-LIMA), performed using robotic bipolar diathermy, followed by a hand-sewn anastomosis to the left anterior descending artery (LAD) through a Minimally Invasive Direct Coronary Artery Bypass approach (R-MIDCAB). MATERIALS AND METHODS: Fifty-seven patients underwent the R-MIDCAB procedure at the SS. Annunziata Hospital in Chieti between May 2024 and November 2025, performed by a single primary surgeon using cl-LIMA technique. Console operating times were evaluated using cumulative sum (CUSUM) analysis. A risk-adjusted CUSUM (RA-CUSUM) model was then constructed, incorporating postoperative complications that were more frequent, clinically significant, and directly influenced by operator performance. RESULTS: After reaching its peak around the early cases, the CUSUM curve showed a steady and uninterrupted downward trajectory. None of the major complications (death within 30 days, major cerebrovascular events, or perioperative myocardial infarctions) occurred. The RA-CUSUM analysis showed no signs of deterioration in performance throughout the entire study period. CONCLUSIONS: Robotic harvesting using cl-LIMA technique has been proposed to simplify LIMA take down. In fact, cl-LIMA technique promoted the learning process and did not emerge to be associated with a worsening of the clinical outcome with regards to the most expected complications. Additional data are needed to confirm its safety and efficacy.