Surgical technique of articulated instruments in endoscopic (ARTISTIC) mastectomy: bridging the gap in minimally invasive breast surgery

Introduction

Background

Breast cancer remains the most diagnosed malignancy among women in Singapore. With the implementation of national screening mammography and increasing awareness, a growing proportion of breast cancers are detected at an early stage. As a result, the objectives of breast cancer surgery have evolved beyond achieving oncologic safety to also prioritise favorable cosmetic outcomes, preservation of upper-limb function, and optimisation of quality of life for patients (1).

Minimally invasive breast surgery (MIBS), incorporating endoscopic- or robotic-assisted techniques, has emerged as an important modality to support these goals. Reported benefits of MIBS include superior cosmetic results due to strategically placed “hidden” incisions, preservation of upper-limb function, shorter recovery periods, and improved postoperative pain control and quality of life (2-5). Nevertheless, MIBS also presents technical challenges, especially for endoscopic mastectomy performed with conventional straight laparoscopic instruments (CLI). These challenges relate to limited manoeuvrability, restricted working angles, the fulcrum effect of trocar access, and ergonomic strain on the operating surgeon.

Rationale

Robotic platforms can overcome many of these limitations by offering wristed articulation, 3D visualisation, and tremor filtration (6,7). However, their widespread adoption is constrained by high capital and maintenance cost, as well as the need for dedicated infrastructure and specialised training. In many settings, this limits patient access to minimally invasive oncologic breast surgery.

Handheld articulating instruments (HAIs) such as the Artisential^® system (LivsMed Inc., Seongnam, Republic of Korea) aim to bridge this gap between conventional endoscopic mastectomy and robotic mastectomy. Compared to conventional CLI, these devices provide robotic-like wrist articulation and increased degrees of freedom while remaining usable through standard trocars and without a separate console. Movements of the surgeon’s hand and wrist are transmitted directly and intuitively to the instrument tip, enhancing dexterity while potentially improving ergonomics (8-13). Robotic surgery is known to be costly and might not be readily available in many regions of the world. By using HAI, we can overcome cost and availability issues stemming from the use of robotic platforms, as HAI is compatible with a conventional laparoscopic setup.

Our centre adopted Artisential^® articulating instruments for endoscopic mastectomy with the goal of improving surgical efficiency and ergonomics, and providing a cost-effective and accessible alternative to robotic systems.

Objective

This manuscript describes, in a step-by-step manner, our technique of ARTiculated InSTrument for endoscopIC (ARTISTIC) mastectomy using Artisential^® articulating instruments. We highlight preoperative preparation, intraoperative workflow, key technical steps, and ergonomic advantages, and discuss the potential role of articulating instruments within the broader landscape of MIBS. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-586/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Ethics board approval was not required for this surgical technique description. Written informed consent was obtained from all individual participants for the publication of their clinical photographs and any accompanying images.

Patient selection

Patients with early-stage breast cancer who are suitable candidates for nipple- or skin-sparing mastectomy may benefit from this surgical approach. There should be no extensive skin involvement, chest wall fixation or features of inflammatory breast cancer. Patients should be appropriately counselled regarding scar placement, oncologic equivalence, and the potential need for conversion to an alternative surgical approach if required.

Contraindications for this technique are similar to contraindications for patient to undergo nipple- or skin-sparing mastectomy which include extensive skin or chest wall involvement or features of inflammatory breast cancer.

Preoperative assessment

Preoperative assessment includes mammography and breast ultrasound for all patients, with breast MRI performed where indicated. This evaluation focuses on assessing tumour extent, its distance to the nipple-areolar complex (NAC), and the presence of multifocal disease. Complex or borderline cases should be discussed within a multidisciplinary team meeting.

Marking and incision planning

Marking and incision planning involve preoperative marking of the anatomical breast borders and key landmarks. The incision is planned along the anterior axillary line to achieve a well-hidden scar while still providing adequate access for dissection and specimen retrieval.

Equipment

The required equipment includes Artisential^® monopolar scissors as the primary dissecting instrument, along with a standard 8–10 mm trocar and a compatible endoscopic system. Lighted retractors are used for initial creation of the working space, with CO₂ insufflation system and an endoscopic stack during the endoscopic part. Conventional laparoscopic instruments should also be available as backup.

Team and positioning

The patient is positioned supine, with the ipsilateral arm either abducted to 90 degrees or placed at the side. The surgeon and assistant are positioned to optimise ergonomics, with the monitor placed directly in front of the primary surgeon. The operating team should be familiar with laparoscopic principles and trained in the use of articulating instrument mechanics.

Step-by-step description

Step 1: Skin incision and creation of access

A 3–4 cm incision is made along the anterior axillary line at approximately the NAC level, providing both cosmesis and adequate access for dissection and specimen extraction (Figure 1).

Figure 1 Incision at the anterior axillary line. Well placed (hidden) anterior axillary line incision used in minimally invasive breast surgery to optimise cosmetic outcomes while maintaining adequate exposure.

Step 2: Marking of the breast footprint and tumescent injection for hydrodissection

Marking gel (mixture of blue dye with sterile gel) is injected along the anatomical borders of the breast to delineate the dissection field. Hydrodissection is also performed with the use of tumescent solution, a physiological saline mixed with adrenaline and lignocaine, allowing clearer identification of the planes for subsequent flap creation (Figure 2).

Figure 2 Injection of marking gel along the breast borders. Marking of anatomical footprint to assist in dissection.

Step 3: Working space creation

A working space of approximately 5 cm is created both anteriorly and posteriorly. Anterior skin flap creation is initiated through the axillary incision using lighted retractors and standard instruments (Figure 3). This working space creation allows for direct visual confirmation of flap thickness and helps the surgeon become oriented to the dissection plane.

Figure 3 Creation of the anterior skin flap using lighted retractors ensures a consistent flap thickness and safe superficial dissection before initiating the endoscopic phase.

Subcutaneous tunnelling is performed as needed, and the working space is established. Trocars are inserted according to the surgeon’s preference and local protocol. Once a satisfactory plane has been established, the procedure transitions to purely endoscopic dissection.

Step 4: Introduction and setup of Artisential^® monopolar scissors

The Artisential^® monopolar scissors are introduced via the working port. The device has an 8-mm shaft with a pistol-grip handle, incorporating jaw-control rings that allow the surgeon to open and close the blades using the thumb and index finger, while wrist movements are transmitted to the articulating tip (8-13) (Figure 4).

Figure 4 Artisential^® monopolar scissors. The pistol-grip handle with jaw-control rings allows fine control of the end effector, while wrist articulation is transmitted directly to the instrument tip.

Step 5: Articulation-assisted dissection of the anterior flap

Endoscopic dissection of the anterior flap proceeds using the monopolar scissors under CO₂ insufflation. The articulating tip permits fine adjustments in angle and direction while maintaining a comfortable wrist posture (Figure 5).

Figure 5 Neutral wrist posture during dissection with Artisential^® instruments. Wristed articulation enables subtle hand and finger movements to be translated to the instrument tip without excessive wrist flexion or extension.

Articulation is particularly useful when working around convex surfaces and in areas where straight instruments would require awkward angles. Controlled traction-countertraction is achieved by coordinating the articulating scissors with a countertraction instrument.

Step 6: Comparison with conventional straight laparoscopic instruments

For comparison, use of a conventional rigid laparoscopic grasper requires significant wrist flexion or extension to achieve the same angulation, especially when working at the upper or medial poles of the breast.

This contrast (Figures 5,6) highlights the ergonomic advantage of articulating instruments in maintaining neutral joint positions.

Figure 6 Wrist flexion when using a conventional straight laparoscopic grasper (left hand, yellow line). Demonstrates ergonomic limitations of straight instruments, with increased wrist strain at extreme working angles.

Step 7: Posterior plane dissection and completion of mastectomy

Dissection continues along the posterior plane, carefully separating the breast tissue from the pectoralis major fascia. The enhanced degrees of freedom provided by the articulating instrument help the surgeon to maintain optimal visualisation and instrument orientation in deep or narrow spaces.

After complete mobilisation, the specimen is retrieved in its entirety through the axillary incision. Reconstruction, if planned, is performed according to institutional protocols.

Step 8: Haemostasis, drain placement, and closure

Meticulous haemostasis is confirmed, and drains are placed as required. The axillary incision is closed in layers to optimise cosmetic outcome.

Postoperative considerations and tasks

Postoperatively, patients undergo routine monitoring of wound and drain output to ensure early detection of any complications. Multimodal analgesia is used to optimise pain control and support early mobilisation. Shoulder and arm range-of-motion exercises are initiated soon after surgery to reduce stiffness and promote functional recovery. Before discharge, patients receive clear instructions on wound and drain care to facilitate safe recovery at home. Scheduled follow-up appointments are arranged to monitor wound healing, assess oncologic outcomes, and evaluate overall patient satisfaction.

Tips and pearls

When adopting articulating instruments, it is advisable to begin with simpler cases to allow the surgeon to become familiar with the mechanics of articulation. During the initial phase of learning, articulation should be performed slowly and deliberately to maintain control and avoid unintended movements. Using an articulating instrument together with a straight instrument provides optimal countertraction and improves operative stability. Surgeons should also avoid excessive articulation, as over-angling the instrument tip can compromise depth perception. Throughout the procedure, keeping the camera slightly zoomed out helps prevent tunnel vision and maintains a broader operative field.

Conversion to conventional open mastectomy should be considered if the operation cannot be performed safely using the endoscopic technique.

Discussion

Surgical highlights

MIBS is a safe and feasible treatment option for selected patients with early-stage breast cancer and has been associated with high satisfaction, reduced upper-arm pain, and better postoperative upper-extremity function (3-5). However, conventional endoscopic mastectomy with CLI is limited by restricted manoeuvrability and the fulcrum effect, contributing to a steep learning curve, longer operative times, and surgeon discomfort (6,7).

Articulating instruments provide an intuitive and ergonomic solution to these limitations. By incorporating wrist-like joints at the instrument tip, they offer seven to eight degrees of freedom, similar to robotic platforms, while maintaining the simplicity and accessibility of a handheld device (8-13). In our experience, the ability to maintain a neutral wrist posture while working at extreme angles is particularly valuable in endoscopic mastectomy, where the working space is both curved and confined.

In the first five cases of articulated instruments in endoscopic (ARTISTIC) mastectomy performed in our institution, the mean operative time was 200±60 minutes, with minimal blood loss (less than 5 mL) and no early complications within 30 days. In comparison, the mean operative time for endoscopic mastectomy using CLI is 248.5±87.3 minutes, and is shorter in experienced hands (204.5±44.5 minutes) (3).

Strengths and limitations

In this setting, the strengths of Artisential^® instruments include enhanced dexterity and improved access to difficult areas of the breast, as well as intuitive hand-instrument synchrony that facilitates precise tissue handling. Improved ergonomics have also been reported (8,13), with reductions in shoulder, back, and forearm strain in prior HAI studies. Additionally, evidence from colorectal and other abdominal surgery suggests a potentially shorter learning curve compared with fully robotic systems (11-13).

Limitations include the single-use nature of the device, which increases per-case costs, and the need for dedicated training to achieve proficiency and avoid over-articulation. In addition, Artisential^® instruments lack inherent tremor filtration and 3D imaging when compared to robotic platforms. The current evidence base specific to breast surgery remains limited, highlighting the need for further dedicated studies.

Comparison with other surgical techniques and researches

MIBS has been studied extensively using both endoscopic and robotic approaches, with multicentre trials demonstrating comparable oncologic outcomes and improved cosmetic and functional results in selected patients (2-5,7,14-16). HAIs have been evaluated in upper gastrointestinal, colorectal, urologic, and paediatric surgery, where they have been shown to be safe and feasible, with promising effects on efficiency and ergonomics (8-13).

In comparison to CLI, HAI offers greater freedom of movement and more natural hand-instrument coordination. Compared with robotic surgery, articulating instruments provide many ergonomic benefits without the requirement for a console or complex setup, although they cannot replicate all the advantages of robotics (such as tremor filtration and 3D magnified vision) (6,7). A learning curve of approximately 10 procedures has been reported for surgeons to gain proficiency with Artisential^® in colorectal surgery, suggesting that adoption may be feasible without extensive training programs (11).

Implications and actions recommended

Other HAIs, such as the HandX™ platform (17) and the SOLOASSIST II^® Robotic arm (18), have been described in the literature in recent years with the same aim of bridging the gap between endoscopic and robotic mastectomy.

Articulating instruments represent a pragmatic and scalable enhancement to endoscopic mastectomy, particularly in resource-constrained settings. Their use may facilitate broader adoption of MIBS in centers without access to robotic platforms, improve surgeon comfort and long-term sustainability of practice by reducing musculoskeletal strain, and potentially reduce operative times as experience is gained along the learning curve.

Key recommended actions include incorporating articulating instruments into structured training pathways for breast surgeons interested in MIBS. In addition, prospective evaluation of operative duration, complication rates, ergonomic outcomes, and patient-reported results is needed, along with formal cost-effectiveness analyses comparing CLI-only, articulating instrument-enhanced and robotic mastectomy approaches.

Conclusions

Articulating instruments are a safe and feasible adjunct in endoscopic breast surgery. By enhancing dexterity and ergonomics without the need for a dedicated robotic platform, they offer a practical bridge between conventional endoscopic surgery and robotics. Their adoption may shorten the learning curve, reduce surgeon strain, and improve the accessibility of MIBS for patients with early breast cancer. Future studies should further define their impact on long-term oncologic outcomes, cost-effectiveness, and patient-reported quality of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Visnu Lohsiriwat and Chayanee Sae-Lim) for the series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” published in Gland Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-586/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-586/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-1-586/coif). The series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all individual participants for the publication of their clinical photographs and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Mok CW, Lai HW. Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes. Breast 2019;46:144-56. [Crossref] [PubMed]
2. Lai HW, Chen ST, Tai CM, et al. Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost. Ann Surg Oncol 2020;27:2255-68. [Crossref] [PubMed]
3. Lai HW, Chen DR, Liu LC, et al. Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P). Ann Surg 2024;279:138-46. [Crossref] [PubMed]
4. Gui Y, Chen Q, Li S, et al. Safety and Feasibility of Minimally Invasive (Laparoscopic/Robotic-Assisted) Nipple-Sparing Mastectomy Combined with Prosthesis Breast Reconstruction in Breast Cancer: A Single-Center Retrospective Study. Ann Surg Oncol 2022;29:4057-65. [Crossref] [PubMed]
5. Wang ZH, Qu X, Teng CS, et al. Preliminary results for treatment of early stage breast cancer with endoscopic subcutaneous mastectomy combined with endoscopic sentinel lymph node biopsy in China. J Surg Oncol 2016;113:616-20. [Crossref] [PubMed]
6. Morrow M. Robotic mastectomy: the next major advance in breast cancer surgery? Br J Surg 2021;108:233-4. [Crossref] [PubMed]
7. Lai HW, Chen ST, Mok CW, et al. Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results. J Plast Reconstr Aesthet Surg 2020;73:1514-25. [Crossref] [PubMed]
8. Parente G, Thomas E, Cravano S, et al. ArtiSential(®) Articulated Wrist-Like Instruments and Their First Application in Pediatric Minimally Invasive Surgery: Case Reports and Literature Review of the Most Commonly Available Robot-Inspired Devices. Children (Basel) 2021;8:603. [Crossref] [PubMed]
9. Hirano Y, Inaki N, Ishikawa N, et al. Laparoscopic Treatment for Esophageal Achalasia and Gastro-Esophago-reflex Disease Using Radius Surgical System. Indian J Surg 2013;75:160-2. [Crossref] [PubMed]
10. van der Vliet WJ, Spaans LN, Bonouvrie DS, et al. Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery. J Laparoendosc Adv Surg Tech A 2022;32:422-6. [Crossref] [PubMed]
11. Shin HR, Oh HK, Ahn HM, et al. Comparison of surgical performance using articulated (ArtiSential®) and conventional instruments for colorectal laparoscopic surgery: A single-centre, open, before-and-after, prospective study. Colorectal Dis 2024;26:2092-100. [Crossref] [PubMed]
12. Vigneswaran HT, Dobbs RW, Huang J, et al. Use of a Novel Articulating Laparoscopic Needle Driver for Partial nephrectomy: An Initial Experience. Urology 2019;132:123-9. [Crossref] [PubMed]
13. Criss CN, Jarboe MD, Claflin J, et al. Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study. J Laparoendosc Adv Surg Tech A 2019;29:542-50. [Crossref] [PubMed]
14. Lai HW, Chen ST, Lin YJ, et al. Minimal Access (Endoscopic and Robotic) Breast Surgery in the Surgical Treatment of Early Breast Cancer-Trend and Clinical Outcome From a Single-Surgeon Experience Over 10 Years. Front Oncol 2021;11:739144. [Crossref] [PubMed]
15. Lai HW, Lin HY, Chen SL, et al. Endoscopy-assisted surgery for the management of benign breast tumors: technique, learning curve, and patient-reported outcome from preliminary 323 procedures. World J Surg Oncol 2017;15:19. [Crossref] [PubMed]
16. Hung CS, Chang SW, Liao LM, et al. The learning curve of endoscopic total mastectomy in Taiwan: A multi-center study. PLoS One 2017;12:e0178251. [Crossref] [PubMed]
17. Messer N, Yehuda AB, Manoskin Y, et al. Performance and operative outcomes' evaluation of a hand-held articulating laparoscopic device: a prospective clinical trial on the HandX™ platform. J Robot Surg 2025;19:401. [Crossref] [PubMed]
18. Peralta-Castillo GG, Bajonero-Canónico P, Valladares-Yañez CM. Bridging Technology: Endoscopic Nipple-Sparing Mastectomy Using SOLOASSIST II® Robotic Arm. CRSLS 2025;12:e2025.00100.