Endoscopic and Da Vinci robotic-assisted surgery in breast cancer: a narrative review of current evidence, technical advances, and future perspectives

Introduction

Breast cancer is among the most frequently diagnosed malignancies in women worldwide and accounts for approximately 12.5% of all newly diagnosed malignancies annually at present (1). Improvements in screening, comprehensive systemic therapy and surgery have substantially prolonged survival. With increasing numbers of long-term survivors, the contemporary surgical philosophy emphasises preserving oncological safety while improving aesthetic outcomes and patient satisfaction.

At present, mastectomy and breast-conserving surgery (BCS) are accepted as first-line surgical treatments for early-stage breast cancer. Nipple-sparing mastectomy (NSM), which preserves the entire skin envelope and the nipple-areola complex (NAC), is an oncologically safe option for appropriately selected patients and offers superior aesthetic results when combined with immediate reconstruction (2,3). Conventionally, the open NSM may, however, be complicated by visible scarring, skin-flap ischaemia, and NAC necrosis; the risk of ischaemic complications is higher in patients with large ptotic breasts or chest-wall deformities such as pectus excavatum (4,5). These limitations have motivated the development of less invasive approaches.

Endoscopic breast surgery (EBS) was first developed by Japanese and Taiwanese medical institutions in the early 2000s as a minimal-incision approach for breast cancer (6,7). More recently, the introduction of the Da Vinci robotic surgical system has provided a further technological advance for NSM and immediate breast reconstruction, by combining three-dimensional high-definition visualisation, articulated instrument control, and tremor filtering (8,9).

Although endoscopic and robotic breast surgery have attracted growing attention, and a relatively abundant body of research has accumulated on their oncological equivalence, cost-effectiveness, learning curves, patient selection, and long-term safety, a comprehensive synthesis of this evidence is still lacking. The present review summarises the current literature on endoscopic and Da Vinci robotic-assisted surgery for breast cancer, with a focus on technical considerations, clinical and oncological outcomes, and future research directions. We present this article in accordance with the Narrative Review reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0218/rc).

Methods

We performed a structured literature search on PubMed, Web of Science, Scopus, and the Cochrane Library from database inception to 31 March 2026. A supplementary literature update was subsequently conducted to include relevant studies published through 1 May 2026. The search strategy combined controlled vocabulary [medical subject headings (MeSH) terms] and free-text terms covering three concept blocks: (I) breast cancer (“breast neoplasms”, “breast cancer”); (II) the surgical procedure (“mastectomy”, “nipple-sparing mastectomy”, “breast-conserving surgery”, “axillary lymph node dissection”, “breast reconstruction”); and (III) the technology of interest (“endoscopy”, “endoscopic”, “robot”, “robotic”, “Da Vinci”, “single-port”). Search terms within each concept block were combined with the Boolean operator OR and the three blocks were combined with AND.

Studies were eligible if they reported clinical outcomes of endoscopic or robotic-assisted breast surgery, including BCS, NSM, axillary lymph-node dissection (ALND), or breast reconstruction. Eligible study designs were randomised controlled trials, prospective and retrospective cohort studies, case series of more than 10 patients, systematic reviews, and meta-analyses. Editorials, commentaries, case reports of single patients, and non-English language publications were excluded unless they were considered seminal references. Two authors (J.Y. and Z.S.) independently screened titles and abstracts and then full texts; disagreements were resolved by discussion with a third author (J.C.). Reference lists of included articles and of recent systematic reviews were hand-searched to identify additional studies.

Findings were synthesised narratively and organised by surgical procedure [EBS for BCS, EBS for NSM, robotic-assisted NSM (RNSM), robotic BCS, robotic ALND, robotic reconstruction] and by outcome domain (oncological safety, perioperative outcomes, skin-flap and NAC viability, cosmesis, and patient-reported outcomes, learning curve, cost). A summary of the search and selection process is shown in Table 1.

EBS in breast cancer

Historical development and technical principles

Endoscopic techniques were initially used in benign breast disease, including aesthetic breast augmentation, and were extended to oncological breast surgery in the late 1990s and early 2000s. Friedlander and colleagues first reported endoscopic subcutaneous mastectomy in 1995 (10). The application of endoscopy to oncological breast surgery was subsequently led by Asian groups, particularly those of Kitamura, Tamaki, and Fukuma in Japan. In 2002, Kitamura et al. published the first clinical series of endoscope-assisted subcutaneous mastectomy and reconstruction for breast cancer, demonstrating its technical feasibility (7). Lai and colleagues at Changhua Christian Hospital, Taiwan (China), have since systematically developed endoscopic-assisted breast surgery (EABS) for BCS and NSM over more than a decade (11,12).

EBS removes the mammary gland through a small skin incision, typically 2 to 4 cm long, usually placed in the axillary fold or peri-areolar region. An endoscopic retractor lifts the skin flap and provides magnified visualisation of the subcutaneous and retro-mammary planes; energy devices such as the Harmonic scalpel, LigaSure, or Thunderbeat are used for tissue dissection and haemostasis purposes (6,13). The two main working planes are the subcutaneous plane for skin-flap elevation and the retro-mammary plane along the pectoralis major fascia. Hydro-dissection is commonly used in the subcutaneous plane to facilitate atraumatic flap elevation.

Endoscopic BCS (E-BCS)

E-BCS has been evaluated in several single-institution series of early-stage breast cancer (T1–T2, N0–N1). Lai et al. reported their preliminary experience with E-BCS at Changhua Christian Hospital, Taiwan (China), covering 100 consecutive procedures and demonstrating acceptable oncological outcomes, a learning curve consistent with that of other minimally invasive breast operations, and favourable patient-reported aesthetic results (14). After a median follow-up exceeding 6 years, local recurrence rates were within the range reported for conventional BCS (C-BCS).

Li et al. [2024] performed a meta-analysis published in Frontiers in Oncology that systematically compared E-BCS with C-BCS (15). The pooled analysis showed that, compared with C-BCS, E-BCS was associated with shorter visible incisions, reduced intra-operative blood loss, and a shorter duration of post-operative drainage, but a longer operative time. There were no significant differences between groups in local recurrence rates, positive-margin rates, or overall complication rates. Cosmetic satisfaction, measured with the validated BREAST-Q questionnaire, was significantly higher in the endoscopic group than in the conventional group.

Lee et al. [2006] reported high cosmetic satisfaction and no major complications following endoscopy-assisted BCS in carefully selected patients (16). Ozaki and Ohara have provided a detailed description of the technical aspects of endoscopy-assisted BCS (17).

Endoscopic NSM (E-NSM)

E-NSM is technically demanding. It is performed through hidden axillary or peri-areolar incisions and aims at complete glandular resection while preserving the entire skin envelope and the NAC (18). Lai et al. conducted a large single-institution cohort of 3,426 operable breast cancer patients, comparing EABS with conventional open surgery using propensity score matching (19). After a median follow-up of more than 12 months, EABS showed comparable disease-free and overall survival to conventional surgery in most patient subgroups.

Du et al. provided complementary medium-term outcome data on E-NSM combined with immediate implant-based reconstruction for early-stage breast cancer (20). A systematic review and meta-analysis of endoscopic vs. open NSM published in the British Journal of Surgery [2025] pooled data from 13 trials. Overall, the endoscopic approach did not adversely affect oncological prognosis (median follow-up to 52 months) and was associated with significantly better cosmetic satisfaction and lower rates of NAC and skin-flap necrosis than the conventional open approach.

Limitations of endoscopic techniques

Despite encouraging outcomes, EBS has several technical limitations (21). Standard endoscopic systems provide only two-dimensional visualisation, which limits depth perception and spatial awareness during dissection. The rigid endoscope has limited manoeuvrability within the curved breast surgical plane and may lead to surgeon fatigue during prolonged procedures. Furthermore, no standardised training programme exists, and the procedure has a steep learning curve, which has limited its dissemination beyond specialised centres, most of which are in East Asia. These limitations have provided much of the rationale for the development of robotic platforms for breast surgery.

Da Vinci robotic-assisted surgery in breast cancer

Development and rationale for robotic breast surgery

Robotic surgical systems have been applied to breast cancer surgery for over a decade. Toesca and colleagues at the European Institute of Oncology in Milan first reported the use of the Da Vinci platform for prophylactic bilateral NSM in a BRCA mutation carrier, with subsequent feasibility and safety studies confirming the role of RNSM (22). Sarfati et al. [2018] confirmed the feasibility and safety of RNSM with immediate prosthetic breast reconstruction in a prospective European study (23). The principal differences among conventional open NSM, E-NSM, and RNSM are summarised in Table 2.

Several technical features make the Da Vinci system attractive for breast surgery. First, the three-dimensional high-definition endoscope provides stereoscopic vision with up to ten-fold magnification, allowing precise identification of the tissue plane and the preservation of thin, uniform mastectomy skin flaps over the breast parenchyma. Second, the EndoWrist instruments offer seven degrees of freedom, exceeding the dexterity of conventional endoscopic instruments and the human wrist. Third, motion scaling and tremor filtering improve fine motor precision, which is particularly advantageous during dissection close to the NAC and the chest wall.

RNSM: surgical technique

The surgical technique for RNSM has been progressively refined in centres in South Korea, Taiwan (China), Italy, and the United States (24,25). A 3–5 cm incision is made along the axillary fold or the mid-axillary line. Initial subcutaneous dissection is performed by conventional means to create an optical working cavity. Then the robot is docked, and the mastectomy is completed through the subcutaneous and retro-mammary planes from lateral to medial under robotic control (9). Sentinel lymph-node biopsy (SLNB) or ALND may be performed simultaneously through the same axillary access. After the mastectomy, the robot is undocked and the specimen is retrieved through the axillary incision. Immediate reconstruction is performed using an implant or an autologous flap. Acellular dermal matrix (ADM) and titanium-coated polypropylene mesh are frequently used to support the implant pocket and improve reconstruction results (18,25).

Da Vinci Xi multi-port system

The Da Vinci Xi platform has four robotic arms and has been the most extensively evaluated system for RNSM. Park et al. [2022] conducted an international multicentre pooled analysis of Korean, Taiwanese, and Italian cohorts and found lower postoperative complication and nipple necrosis rates after RNSM than after conventional NSM, with no significant difference in oncological outcomes (26).

Lai et al. [2024] conducted a prospective multicentre study published in the Annals of Surgery, comparing RNSM with conventional NSM and ENSM (each with immediate prosthetic reconstruction, n=38 in the robotic arm) (11). In that trial, RNSM was associated with a complication rate comparable to that of conventional NSM, but incurred higher overall procedural costs because of the consumables required by the robotic platform and the longer operating time. However, patient-reported outcomes were significantly more favourable for the robotic group with respect to visible scarring and aesthetic judgment (11).

Angarita et al. published one of the earliest systematic reviews of RNSM in the British Journal of Surgery, summarising the early evidence on feasibility, safety, and oncological outcomes (27).

Da Vinci single-port (SP) system: the latest evolution

The Da Vinci SP system represents a substantial advance over the multi-arm Xi platform. The SP system features a single 25 mm cannula housing an articulated three-dimensional endoscope together with three articulated working instruments allowing the entire instrument cluster to enter the body through a single incision. The single-arm design reduces external arm clashes, which can be problematic in the spatially constrained breast operative field.

Lee et al. [2025] reported a retrospective study of 60 women who underwent SP robot-assisted unilateral or bilateral NSM with immediate reconstruction at Asan Medical Center, Seoul (28). No conversions to multi-port robotic or open surgery were required. Median operative time was 154 minutes, median hospital stay was 5.5 days, and no recurrences were observed within 6 months of follow-up. Farr et al. [2024], in JAMA Surgery, reported a single-centre experience of SP RNSM in the United States and confirmed the safety and feasibility of the technique, with favourable peri-operative outcomes (29). Haddock et al. subsequently described the use of profunda artery perforator (PAP) flaps for reconstruction after SP RNSM, broadening the reconstructive options available for these patients (30).

Robotic BCS

Most published reports of robotic breast surgery have focused on NSM, but recent work has explored SP robotic platforms for BCS. Yu et al. [2025] reported a prospective, single-arm, phase IIa trial of transaxillary SP robotic-assisted partial mastectomy combined with SLNB in six patients with early-stage breast cancer at Daping Hospital, China (31). This is the first reported series using a SP robotic system specifically for BCS, and the early results suggest technical feasibility and short-term safety.

Robotic ALND (R-ALND)

Da Vinci R-ALND has been proposed as an alternative to conventional ALND in selected patients. Chen et al. [2022] compared 60 patients allocated to R-ALND vs. conventional ALND (32). The robotic group had significantly lower rates of wound infection, fat necrosis, and upper-limb lymphoedema. These findings suggest that the robotic platform can improve the precision and safety of axillary resections, although further validation in larger studies is required.

Robotic-assisted breast reconstruction

The Da Vinci system has also been applied to autologous breast reconstruction (33). Robotic harvest of the latissimus dorsi (LD) flap and the deep inferior epigastric perforator (DIEP) flap has been reported. Eo et al. [2023] compared robotic LD flap harvest with endoscopy and conventional open approaches, demonstrating reduced donor-site morbidity with the robotic technique (34). Chen et al. reported RNSM with immediate LD muscle reconstruction without the use of an island flap, underscoring the versatility of robotic platforms in reconstructive breast surgery (32). Direct-to-implant reconstruction has also been combined successfully with robot BCS, with outcomes comparable to or better than those of open conventional procedures (25,35).

Comparative outcomes: endoscopic vs. robotic vs. conventional surgery

Oncological safety

Nessa et al. [2024], in a meta-analysis published in the British Journal of Surgery, found no statistically significant differences in postoperative complications or surgical outcomes between robotic and conventional NSM, based on patients pooled from seven studies across four countries worldwide (36). Park et al. [2025] systematically reviewed the oncological safety of RNSM and found short-term oncological equivalence to conventional NSM (37). Lin et al. [2025] reported data from an Asian centre on 266 cases of RNSM with a median follow-up of 37.2 months; the 5-year overall survival rate was 98.3% (35). Wang and colleagues performed a systematic review and meta-analysis and confirmed that RNSM does not compromise short-term perioperative safety or oncological outcomes compared with conventional procedures (38).

Notwithstanding these favourable comparisons, it must be emphasised that the available oncological data are predominantly short- to medium-term. Most multicentre series report median follow-up of less than 36 months, and only a handful of single-centre studies have follow-up beyond 5 years. Given that breast cancer recurrence (particularly in hormone-receptor-positive disease) may occur late, the current oncological equivalence of EBS and RNSM should be regarded as provisional, pending long-term outcomes from prospective randomised trials such as NCT06738654.

Perioperative outcomes

The available literature shows that minimally invasive (endoscopic or robotic) procedures are associated with favourable perioperative profiles in selected outcome domains. Intraoperative blood loss is generally less because of the magnified visualisation and the use of advanced energy devices (36,39). Hospital length of stay is variable across studies; some series report shorter stays after minimally invasive surgery (MIS), whereas others find comparable durations. Postoperative pain scores tend to be similar to or slightly lower than those after conventional open surgery.

Operative time remains the principal disadvantage of both endoscopy and robotic procedures. The meta-analysis by Xu et al. [2024] found that minimally invasive NSM was associated with a mean operative time approximately 47 minutes longer than conventional NSM (39). Operative time decreases substantially with accumulated institutional experience (11,40). An et al. [2025], in a network meta-analysis of robotic, conventional, and E-NSM with immediate prosthetic reconstruction, reported consistent trends across surgical outcomes (41).

Skin-flap and NAC viability

Skin-flap and NAC viability are among the most clinically important advantages of RNSM. The magnified three-dimensional visualisation and articulated instruments of the Da Vinci platform allow more accurate preservation of the subdermal vascular network during skin-flap elevation (42). Nodiţi et al. [2024] reported that two studies found significantly lower skin and NAC necrosis rates after RNSM than after conventional NSM (0% vs. 12.5% and 2.4% vs. 15.2%, respectively) (43). NAC necrosis remains the most clinically significant aesthetic complication of conventional NSM, and its reduction is one of the principal arguments in favour of robotic approaches.

Cosmetic outcomes and patient satisfaction

Cosmetic outcomes and patient-reported satisfaction consistently favour minimally invasive techniques. Hidden axillary or peri-areolar incisions used in endoscopic and robotic approaches reduce visible chest-wall scarring compared with conventional mastectomy (42,44). Several studies have shown that domain scores of the BREAST-Q questionnaire (satisfaction with breasts, psychosocial well-being, and physical well-being) are higher after robotic breast surgery or EBS than after conventional surgery. Kim et al. [2024], in a multicentre retrospective study published in JAMA Surgery, found that minimal-access NSM had postoperative complication rates comparable to conventional NSM and a significantly shorter final incision length (45). Wan et al. analysed whether longer follow-up of minimally invasive breast cancer surgery was associated with worse oncological outcomes and did not identify an increased oncological risk (40).

Learning curve and training considerations

A substantial body of work has examined the learning curves for endoscopic and robotic breast surgery. Cumulative sum (CUSUM) analysis by Lai et al. [2019] showed that docking time, RNSM time, and total time for RNSM and immediate prosthesis breast reconstruction decreased after 13, 13, and 12 procedures, respectively (19). Chen and Lu [2025] studied the learning curve for Da Vinci RNSM with immediate implant-based breast reconstruction and reported that proficiency was reached after 27 cases (46). Loh et al. [2021] similarly observed that efficiency and outcomes improved progressively during the initial training phase, with the most marked gains within the first 30 procedures (47).

For E-BCS, Lai et al. reported that operative time decreased significantly after 15 consecutive cases (14). Hung et al. confirmed, in a multicentre learning-curve study, that a structured proctorship system and institutional support were essential for overcoming the learning curve of endoscopic mastectomy (48). At present, no standardised training programme exists. Available training combines simulation-based courses, cadaveric practice sessions, and proctored clinical experiences, but these components have not yet been harmonised across institutions or countries.

Economic considerations and cost-effectiveness

Cost is one of the principal barriers to the wider adoption of robotic-assisted breast surgery. The capital cost of a Da Vinci surgical system is approximately 1.5–2.5 million United States dollars, with substantial recurring expenses for maintenance contracts, disposable instruments, and drapes (49). Turchetti et al. [2012] reviewed economic evaluations of Da Vinci-assisted surgery across multiple specialties and found that robotic surgery was significantly more expensive than conventional laparoscopic surgery when the purchase and maintenance costs of the robotic system were included (50).

In the multicentre study by Lai et al. [2024], RNSM was US$4,000 and US$2,600 more expensive than conventional NSM and E-NSM, respectively (11). The cost differential was driven mainly by robotic instrument consumables and longer operating times. Proponents argue that improvements in aesthetic outcomes and a lower revision rate may offset some of these costs, but formal economic analyses with quality-adjusted life-year (QALY) endpoints are still lacking. By comparison, EBS has lower initial costs and may therefore be more suitable for resource-constrained settings (14).

Patient selection criteria

Appropriate patient selection is essential for both the safety and the efficacy of minimally invasive breast surgery. The current consensus regarding RNSM is that it is appropriate for patients without skin or chest-wall involvement, with a tumour-to-nipple distance greater than two cm, and with clinical stage I–II disease. Patients with inflammatory breast cancer, multicentric disease with extensive intraductal component, or direct nipple involvement are generally considered to be contraindicated. A body mass index below 30 kg/m² and cup size C or smaller are common selection criteria, although there is growing experience with patients with larger breasts (25,29).

Risk-reducing mastectomy in BRCA mutation carriers is now an established indication for RNSM, and was indeed the first indication reported when the technique was introduced (22). Piper et al. systematically reviewed the effect of total skin-sparing mastectomy on local recurrence and postoperative complications, providing additional criteria to refine patient selection for such procedures (5).

Regulatory caution remains. In a 2019 safety communication, the United States Food and Drug Administration (FDA) warned that robotic-assisted surgical devices had not been cleared for the prevention or treatment of cancer, including breast cancer, because of insufficient clinical evidence regarding their safety and efficacy. To accelerate the safe adoption of these technologies, ongoing prospective data collection and rigorous institutional review-board oversight are essential. Morrow, in an editorial entitled “Robotic mastectomy—the next major advance in breast cancer surgery?”, reviewed the existing evidence and the regulatory landscape and called for further high-quality prospective data.

Future perspectives

Several directions are likely to shape the future of minimally invasive breast surgery. First, continued development of robotic platforms—including the Da Vinci SP system and emerging competitors such as Senhance and Hugo RAS—may improve accessibility through smaller hardware footprints, lower cost, and improved ergonomics (28,44). Second, the integration of artificial intelligence (AI) and augmented reality (AR) into robotic surgical workflows could enable rapid intra-operative tissue recognition, real-time assessment of the resection cavity, and intelligent decision support. Third, fluorescence-guided surgery using indocyanine green (ICG) perfusion monitoring may enhance the success rate of skin-flap revascularisation in robotic breast surgery and EBS by providing objective intra-operative assessment of tissue viability.

From a clinical-evidence perspective, several prospective randomised controlled trials are currently underway to compare RNSM with conventional NSM including a phase III trial registered on ClinicalTrials.gov (NCT06738654) comparing the Da Vinci SP system with conventional open NSM. These trials are needed to generate the long-term oncological data required to develop evidence-based recommendations. Selected ongoing and recently completed prospective trials of robotic breast surgery and EBS are summarised in Table 3.

Indication expansion beyond the current “focus on early-stage breast cancer with a small tumour-to-nipple distance ratio” is also an active area of investigation. Robotic BCS, recently advanced by the Daping Hospital group, is more likely to become more widely available and applicable to broader patient populations (31). The integration of robotic surgery with neoadjuvant systemic chemotherapy for locally advanced disease, or with adjuvant radiotherapy in oncoplastic breast-conserving treatment, remains an active area of investigation. Concurrently, the relevant minimally invasive surgical equipment must be further optimized.

Conclusions

Endoscopic and Da Vinci robotic-assisted surgery have emerged as two principal minimally invasive options for breast cancer surgery. The available evidence indicates that, in carefully selected patients, both approaches can achieve short- to medium-term oncological outcomes comparable to those of conventional open surgery, with superior cosmetic results and lower rates of skin-flap and NAC necrosis. The Da Vinci SP system, in particular, enables true single-incision mastectomy through a concealed axillary approach.

Nevertheless, important gaps in the evidence remain. Long-term oncological outcomes beyond 5 years are sparsely reported; most available studies are single-centre retrospective designs and are therefore susceptible to selection bias. Procedural costs, longer operative times, and the steep learning curve have not yet been fully addressed. Prospective randomised controlled trials with extended follow-up, formal cost-effectiveness analyses, and standardised, competence-based training programmes are urgently required before endoscopic and robotic breast surgery can be recommended as routine care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0218/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0218/prf

Funding: This study was supported by the Shandong Undergraduate Training Programs for Innovation and Entrepreneurship (No. S202411065142).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0218/coif). The authors have no 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.

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