Since 1999, we have performed total endoscopic off-pump coronary artery bypass (OPCAB). Innovation of endoscopic optic techniques and development of endoscopic forceps were necessary to perform this procedure. The operative methods of the endoscopic OPCAB; a 12 mm port for 3-D endoscope is firstly inserted through the 5th intercostal space (ICS) in the mid axillary line, and then the left internal thoracic artery (LITA) is taken down in semi-skeletonized fashion using other 2 instrumental 5 mm ports (the 3rd, 6th anterior axillary ICS). To anastomose LITA to the left anterior descending artery (LAD), other 2 10 mm and 12 mm ports are inserted through the 4th ICS in parallel. A conventional end-to-side anastomosis is manually performed with 8-0 prolene. The average LITA harvesting time and anastomotic time have been shortened significantly thanks to the endoscopic innovation. However, there are some limits to manual manipulations in the endoscopic OPCAB. Robotic surgery might have more advantages to the flexibility of forceps tips. The introduction of robotic surgery system is indispensable to safe and certain endoscopic OPCAB.