We describe the first use of totally endoscopic, off-pump, robot-assisted transmyocardial laser revascularization in a 58-year-old man with refractory rest angina who had undergone two prior coronary bypass operations. Preoperative testing revealed reversible ischemia of the left ventricular apex with diffuse coronary atherosclerotic disease not suitable for further treatment by conventional techniques. During surgery a fiberoptic laser delivery system was manipulated using the da Vinci robotic system to create 25 transmural channels in the left ventricular myocardium. Postoperative recovery was rapid and uneventful, with complete relief of anginal symptoms at 30 days.