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

Minimally invasive breast surgery (MIBS) has emerged as an important surgical option for patients with early-stage breast cancer, driven by growing emphasis on superior cosmetic outcomes, preservation of function, and improved quality of life. Endoscopic nipple- or skin-sparing mastectomy offers the advantages of hidden scars and reduced tissue trauma. However, when performed using conventional straight laparoscopic instruments (CLI), the procedure remains technically demanding because of restricted degrees of freedom, the fulcrum effect of trocar-based access, and suboptimal surgeon ergonomics. Robotic systems can overcome many of these limitations, but remain inaccessible to many institutions due to high capital costs, recurring consumables, and infrastructure requirements. Handheld articulating instruments (HAI), such as the Artisential® system, provide an intermediate solution that combines several benefits of robotic surgical systems, such as wrist-like articulation, enhanced manoeuvrability, and intuitive motion transmission, but without the need for a dedicated robotic platform. This manuscript presents a detailed description of a technique in endoscopic mastectomy using Artisential® articulating instruments, following the SUPER reporting checklist. We outline preoperative preparation, incision planning, anterior flap creation, endoscopic dissection using the articulating monopolar scissors, and specimen retrieval, with emphasis on ergonomic posture, traction-countertraction strategies, and tips to safely navigate difficult angles. Use of articulating instruments allows surgeons to maintain a neutral wrist posture while operating in confined spaces, potentially reducing musculoskeletal strain and shortening the learning curve for MIBS. At the same time, it may mitigate some of the operative time penalties associated with complex endoscopic dissection. Limitations include the single-use nature of the device, additional per-case cost, and the need for specific training to master articulation mechanics. Articulated instruments thus offer a pragmatic, cost-conscious bridge between CLI-based endoscopic mastectomy and fully robotic approaches. Further studies are warranted to evaluate long-term oncologic outcomes, surgeon ergonomics, cost-effectiveness, and patient-reported results in this setting.