One of the most widely acknowledged advantages of MICAB is its ability to significantly shorten recovery times compared to traditional CABG. The procedure eliminates the need for a full sternotomy, reducing trauma to the chest wall and allowing patients to return to normal activities sooner. Studies indicate that MICAB patients experience shorter hospital stays, with many discharged within three to five days postoperatively, compared to seven to ten days for conventional CABG patients [25]. Additionally, MICAB patients demonstrate a reduced dependence on intensive care and require fewer postoperative interventions, contributing to lower hospital resource utilization and healthcare costs [26].

Early mobilization is a crucial factor in preventing complications such as deep vein thrombosis and pulmonary infections following cardiac surgery. MICAB facilitates faster ambulation due to reduced postoperative pain and less reliance on opioid analgesics. Patients undergoing MICAB have reported greater ease in resuming physical activities, including walking and light exercise, within the first few weeks post-surgery [27]. Enhanced recovery protocols tailored for MICAB further optimize rehabilitation, allowing patients to regain functional capacity more rapidly than those who undergo conventional CABG [28].

MICAB significantly decreases the risk of complications associated with traditional CABG, particularly infections, excessive bleeding, and postoperative arrhythmias. Conventional CABG requires opening the chest through a sternotomy, which increases the risk of deep sternal wound infections. MICAB, on the other hand, utilizes smaller incisions that expose patients to fewer external contaminants, thereby minimizing the likelihood of wound-related complications [29, 30, 31]. Furthermore, MICAB procedures can be performed off-pump, eliminating the need for cardiopulmonary bypass (CPB), which has been linked to systemic inflammatory responses and cognitive dysfunction in some patients [32, 33].

The avoidance of CPB also reduces transfusion requirements, improving overall hemodynamic stability during surgery. Studies have reported lower rates of atrial fibrillation—a common postoperative complication following CABG—among patients undergoing MICAB, likely due to reduced systemic inflammation and improved myocardial preservation [34]. These findings suggest that MICAB not only offers equivalent revascularization outcomes but also lowers the risk of complications that negatively impact long-term recovery and patient satisfaction [35].

Traditional CABG leaves patients with a long midline scar, which can be a source of psychological distress, particularly in younger individuals and those concerned with aesthetic outcomes. MICAB eliminates the need for a sternotomy, instead using smaller incisions either under the ribs or in conjunction with robotic-assisted technology, leading to less noticeable scarring and improved cosmetic outcomes [25]. Although cosmetic benefit is often inferred from incision size and surgical access, emerging patient-centered evidence supports this claim. A randomized prospective study comparing patient body image, self-esteem, and scar satisfaction following robot-assisted versus conventional cardiac surgery reported significantly better scores across body image (p = 0.026), self-esteem (p = 0.038), and scar assessment scales (p 0.05), for patients in the robotic group, indicating enhanced cosmetic outcomes with minimally invasive approaches [25]. Patients undergoing MICAB have reported higher levels of confidence and satisfaction with the surgical outcome due to the discreet nature of the incision sites [36].

Beyond cosmetic benefits, smaller incisions result in less wound discomfort and a faster healing process. The reduced surgical trauma decreases postoperative inflammation, allowing patients to experience less pain and minimal restriction in upper body movement. Studies evaluating patient-reported outcomes have noted that individuals undergoing MICAB express greater comfort and mobility when compared to those recovering from traditional CABG, further reinforcing the psychological and functional advantages of minimally invasive approaches [29].

Short-term [37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62] (Table 2, Ref. [37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62]) and long-term [63, 64, 65, 66, 67] (Table 3, Ref. [63, 64, 65, 66, 67]) clinical studies have demonstrated improved patient outcomes with MICAB compared to traditional sternotomy-based CABG. These studies also report that MICAB provides comparable graft patency rates to conventional CABG, particularly when using the left internal mammary artery (LIMA) for left anterior descending (LAD) artery revascularization [13, 20]. The durability of grafts remains a critical factor in determining success rates, and MICAB has proven effective in maintaining functional grafts over extended follow-up periods. Additionally, MICAB patients often report higher postoperative quality of life due to decreased pain and fewer post-surgical complications [36].

Furthermore, MICAB has shown favorable outcomes among high-risk populations, including elderly patients and those with multiple comorbidities. By reducing the physiological stress associated with surgery, MICAB minimizes adverse postoperative events and allows for safer surgical intervention in patients who may not tolerate traditional CABG well [68]. These findings reinforce MICAB as an essential option for selective patient populations, ensuring effective revascularization with reduced surgical risks.

One of the primary drawbacks of MICAB is its technical complexity, which presents a steep learning curve for surgeons. Unlike conventional CABG, which provides a full view of the surgical field through median sternotomy, MICAB requires operating through small incisions or robotic-assisted access, restricting direct visualization and maneuverability [69]. Surgeons must rely on specialized instrumentation and endoscopic or robotic techniques, which demand extensive training and experience to achieve proficiency [70].

Additionally, MICAB requires precise anastomotic techniques under restricted access, increasing the risk of technical errors in less experienced hands. Studies indicate that surgical learning curves for MICAB often exceed those of conventional CABG, with higher initial procedural times and greater dependency on specialized assistance during early cases [71]. As a result, proficiency in MICAB takes longer to attain, and case volumes remain lower compared to traditional CABG in many institutions. This limitation affects surgical consistency and overall success rates in centers with limited exposure to MICAB procedures [70].

MICAB remains inaccessible to many patients and hospitals due to the need for specialized equipment, infrastructure, and trained personnel. Unlike conventional CABG, which can be performed in nearly all cardiothoracic surgical centers, MICAB requires robotic platforms, thoracoscopic tools, and dedicated hybrid operating rooms, making its implementation more resource-intensive [26]. Smaller hospitals and facilities with budget constraints may lack the necessary infrastructure to offer MICAB, limiting patient access to this procedure.

Furthermore, access to surgeons trained in MICAB techniques remains a significant barrier to its adoption. A global survey of cardiothoracic surgeons revealed insufficient exposure and training opportunities as major obstacles to expanding MICAB practices [72]. Given the requirement for specialized robotic and endoscopic training, not all cardiac surgeons receive adequate preparation to perform MICAB, affecting its availability and regional disparities in access [73].

The financial burden associated with MICAB is another critical limitation. The initial investment in robotic-assisted platforms, specialized instruments, and training programs significantly increases the cost of implementing MICAB at surgical centers [74]. Compared to conventional CABG, which utilizes standard operating rooms and widely available instruments, MICAB requires dedicated technological investments, making it financially restrictive for many institutions.

Moreover, longer procedural times during the learning phase contribute to increased operating room expenses, including anesthesia duration, consumables, and surgical personnel costs. Insurance coverage for MICAB procedures varies widely, with reimbursement models often favoring traditional CABG, further restricting financial feasibility for hospitals adopting minimally invasive approaches [26]. While MICAB has the potential for cost savings in terms of shorter hospital stays and fewer postoperative complications, high upfront costs remain a significant barrier to widespread implementation.

Not all patients are eligible for MICAB, as certain anatomical and clinical factors limit its applicability. Multivessel disease, calcified coronary arteries, and complex comorbid conditions pose challenges for MICAB procedures, often necessitating traditional CABG for complete and durable revascularization [24]. Patients with poor pulmonary function or advanced thoracic deformities may also be unsuitable candidates due to restricted surgical access in a minimally invasive setting [3].

Additionally, MICAB is generally preferred for isolated LAD bypasses, whereas patients with extensive coronary disease requiring multiple grafts often undergo conventional CABG to ensure comprehensive revascularization [24]. The selection criteria for MICAB continue to evolve with advancements in robotic and hybrid techniques, but current limitations restrict its availability to select patient populations, limiting its role as a universal alternative to conventional CABG [25].

The continuous development of surgical technology presents a significant opportunity for the refinement and broader adoption of MICAB. Innovations such as robotic-assisted surgery, enhanced imaging techniques, and improved instrumentation have significantly improved precision and procedural outcomes. The integration of artificial intelligence in surgical planning has also contributed to better preoperative assessments, leading to optimized graft placement and reduced intraoperative complications [75].

Robotic-assisted MICAB allows for greater dexterity, improved visualization, and reduced manual fatigue, enabling surgeons to perform intricate anastomoses with superior accuracy. Studies indicate that robotic-assisted coronary revascularization results in fewer technical errors and shorter operating times as surgeons gain proficiency [76]. Additionally, endoscopic and three-dimensional imaging technologies have improved anatomical visualization, allowing for more precise dissection and graft placement, leading to enhanced surgical success rates [24]. The continuous refinement of these technologies presents an opportunity to standardize MICAB techniques, making them more accessible to surgical teams worldwide.

Expanding structured training programs and fellowships for MICAB presents an opportunity to increase surgeon competency and procedural adoption rates. Traditional CABG techniques are widely taught during cardiothoracic surgical training, but MICAB requires specific expertise in minimally invasive approaches, including thoracoscopic and robotic techniques. Currently, the availability of MICAB-focused fellowships is limited, restricting exposure for cardiac surgeons who seek to specialize in minimally invasive coronary revascularization [26].

Standardizing simulation-based learning, mentorship programs, and international surgical workshops would help address training gaps, ensuring that more surgeons develop the technical skills required for MICAB. Studies suggest that structured mentorship programs significantly shorten the MICAB learning curve, improving success rates and reducing complication risks associated with early procedural attempts [26]. Increasing access to such programs would accelerate the widespread adoption of MICAB and improve its overall clinical outcomes.

Greater awareness among patients, healthcare providers, and policymakers presents an opportunity to expand the utilization of MICAB. Many patients remain unfamiliar with minimally invasive options, often assuming that traditional CABG is the only effective approach for coronary revascularization. Increasing patient education efforts through hospital-based information sessions and online resources can help individuals make informed decisions regarding their surgical options [77]. Table 4 summarizes strategic modalities for patient education tailored to MICAB candidates.

Clinicians and primary care providers play a critical role in referring patients to cardiothoracic surgical centers that specialize in MICAB. Raising awareness among healthcare professionals regarding MICAB’s benefits, patient eligibility criteria, and long-term outcomes would facilitate more appropriate referrals. Additionally, healthcare policymakers can develop reimbursement models and funding initiatives to support hospitals in acquiring robotic platforms and expanding MICAB programs, making the procedure more accessible to a broader patient population [75].

Ongoing research efforts present an opportunity to refine MICAB techniques, optimize patient selection criteria, and expand its clinical indications. Future studies evaluating long-term graft patency, multivessel revascularization strategies, and hybrid surgical approaches will further establish MICAB’s efficacy as an alternative to conventional CABG [56].

Clinical trials focusing on robotic-assisted multi-arterial grafting, enhanced intraoperative imaging techniques, and personalized artificial intelligence-driven surgical planning have the potential to improve procedural outcomes and expand MICAB’s role in complex coronary disease management. Additionally, economic studies analyzing the cost-effectiveness of MICAB relative to traditional CABG could provide valuable data for healthcare decision-makers, ensuring that funding structures support the implementation of minimally invasive approaches [78].

The rise of PCI as an alternative to surgical revascularization presents a significant challenge to MICAB’s adoption. Advances in PCI techniques, including drug-eluting stents and improved catheter-based interventions, have expanded the eligibility criteria for nonsurgical revascularization, reducing the number of patients requiring coronary bypass surgery [79]. Many patients with single-vessel or moderate multivessel disease opt for PCI due to its minimally invasive nature and shorter recovery time, creating competition for MICAB within the same patient demographic [80].

Hybrid coronary revascularization, which combines PCI with MICAB, has also gained traction, allowing surgeons to selectively perform bypass surgery on critical coronary arteries while utilizing stenting for less complex lesions [81]. While this approach enhances individualized patient care, it also reduces the number of patients requiring full MICAB procedures, further challenging its widespread implementation. As these alternative techniques continue to evolve, MICAB must demonstrate superior long-term efficacy and improved patient benefits to remain competitive in the field of coronary revascularization.

The implementation of MICAB is subject to stringent regulatory approval processes, which can delay widespread clinical adoption. Many regions require extensive validation of new surgical techniques and technologies before granting approval for routine clinical use [82]. Robotic-assisted MICAB, in particular, faces prolonged certification requirements due to its dependence on specialized equipment and the need for formalized surgeon training programs [74].

In addition to regulatory barriers, hospitals must comply with safety protocols and quality assurance standards, which can restrict access to MICAB procedures. Concerns regarding intraoperative risks, procedural consistency, and long-term outcomes may contribute to conservative decision-making among hospital administrators and surgical boards [74]. Without streamlined regulatory pathways, the integration of MICAB into routine surgical practice remains slow, limiting its accessibility for a wider patient population.

The cost implications of MICAB pose a significant threat to its widespread adoption. While MICAB offers potential long-term cost savings by reducing postoperative complications and shortening hospital stays, the initial financial investment required to establish MICAB programs remains high [26]. Hospitals must allocate substantial resources to acquire robotic platforms, specialized surgical instruments, and dedicated training programs, creating financial barriers for institutions with limited budgets [74].

Reimbursement models further complicate MICAB’s accessibility. Many healthcare systems prioritize reimbursement for conventional CABG and PCI, leaving MICAB with lower financial incentives for providers and hospitals. Without favorable insurance coverage and funding models, MICAB programs may struggle to achieve financial sustainability, slowing their expansion across healthcare institutions [29]. In evaluating the cost-effectiveness of MICAB techniques, it is essential to balance short-term expenditures with long-term outcome benefits. Robotic-assisted approaches, while associated with higher initial costs, have demonstrated potential reductions in postoperative complications, ICU length of stay, and overall recovery time. These downstream efficiencies may offset upfront investment, particularly in high-volume centers with streamlined protocols. Pasrija et al. [18] compared robotic coronary surgery to conventional sternotomy-based procedures and found that despite elevated intraoperative costs, robotic techniques were associated with shorter hospital stays and comparable clinical outcomes, suggesting favorable economic utility in appropriately selected patients.

Addressing economic barriers requires advocacy for updated reimbursement structures and cost-effectiveness studies that highlight MICAB’s long-term benefits.

Patient skepticism regarding MICAB poses another challenge to its widespread acceptance. Despite its advantages, many individuals are hesitant to undergo minimally invasive procedures due to concerns about safety, efficacy, and unfamiliarity with robotic-assisted techniques [74]. Patients often associate CABG with traditional sternotomy-based surgery and may require extensive counseling before opting for MICAB.

Additionally, reports of early-stage technical challenges and variable surgeon expertise may contribute to doubts regarding MICAB’s reliability. While high-volume centers with experienced surgeons report favorable outcomes, newer institutions may struggle with initial learning curve complications, leading to inconsistent patient experiences [74]. Overcoming patient perception challenges requires targeted educational initiatives, improved surgeon training programs, and transparent discussions on procedural risks and benefits.

MICAB offers substantial benefits, including reduced recovery time, lower complication rates, improved cosmetic outcomes, and enhanced patient satisfaction. These strengths provide a compelling case for adopting MICAB as an alternative to traditional CABG, particularly in selective patient populations. However, the procedure faces inherent technical challenges, requiring specialized training and surgical expertise. The steep learning curve and limited availability of trained surgeons restrict the widespread adoption of MICAB, particularly in lower-resource healthcare environments [74].

Another area where strengths and weaknesses intersect is accessibility. While MICAB reduces hospital stays and leads to fewer postoperative complications, its implementation remains financially demanding. The need for robotic-assisted platforms, thoracoscopic tools, and dedicated surgical teams increases operational costs, limiting its availability across different healthcare institutions [24]. Bridging this gap requires an investment in technology, structured surgeon training programs, and policy-level adjustments to ensure MICAB becomes a financially viable option for hospitals and patients.

Although this review utilizes a structured SWOT framework, it is important to acknowledge that such methodology relies predominantly on expert consensus and synthesized literature, rather than direct patient-level data. While multicenter studies with early and long-term outcomes have been summarized (Tables 1,2,3), future research should incorporate patient-reported experiences and real-world registry data to complement strategic analysis. Greater insight into functional recovery, quality of life, and graft durability from longitudinal cohorts will strengthen clinical decision-making and inform broader MICAB adoption.

Integrating MICAB more broadly into surgical practice requires addressing both systemic and procedural barriers. Expanding training programs and fellowship opportunities can increase surgeon proficiency and reduce technical inconsistencies across institutions. Standardized training models, including simulation-based learning and mentorship initiatives, have shown promise in improving MICAB outcomes and facilitating procedural confidence among newly trained surgeons [74].

From a healthcare policy standpoint, reimbursement models must evolve to accommodate MICAB procedures. Many current funding structures prioritize conventional CABG and PCI, leaving MICAB in a financially vulnerable position. Updated reimbursement policies that account for MICAB’s potential long-term benefits—such as reduced postoperative complications and shorter hospital stays—could drive broader adoption and encourage institutions to invest in minimally invasive approaches [74].

Expanding patient awareness is another key strategy for improving MICAB’s adoption rate. Many patients remain uninformed about minimally invasive cardiac surgery options, and targeted education programs led by physicians and healthcare organizations can enhance public understanding. Highlighting MICAB’s cosmetic benefits, faster recovery, and comparable long-term outcomes to traditional CABG can help address patient skepticism and increase demand for minimally invasive revascularization [74].

Table 5 provides a structured summary of MICAB’s core strengths, procedural limitations, and persisting evidence gaps—highlighting both the factors driving its clinical uptake and the areas requiring further empirical substantiation, such as long-term multivessel data, standardized patient-reported outcomes, and cross-institutional reproducibility.

Further research is necessary to refine MICAB techniques, optimize patient selection criteria, and enhance procedural efficacy. Long-term studies evaluating graft patency in MICAB versus traditional CABG will provide insight into whether minimally invasive approaches maintain comparable durability. Additionally, research into hybrid revascularization strategies—combining MICAB with PCI—can help define how best to treat multivessel disease using a minimally invasive framework [81].

Technological advancements will play a critical role in MICAB’s future. Improving robotic-assisted precision, refining three-dimensional imaging techniques, and integrating artificial intelligence into surgical planning could enhance procedural outcomes and minimize technical challenges [74]. Further clinical trials focusing on these innovations would support evidence-based adoption of MICAB across more surgical centers.

Economic studies assessing MICAB’s cost-effectiveness compared to traditional CABG should also be prioritized. A deeper understanding of MICAB’s financial impact, particularly in high-volume cardiac centers, would help policymakers develop better funding models to support minimally invasive surgical programs. Addressing economic concerns through research-backed reimbursement proposals could lead to broader institutional investment in MICAB, ensuring sustainable implementation over the long term [83].