Comment on: “Three Strategic Pillars for Implementing Endoscopic Nipple-Sparing Mastectomy”

Dear Editor,

We read with great interest the methodological article by Peralta Castillo et al, proposing a structured 3-pillar framework for the implementation of endoscopic nipple-sparing mastectomy (E-NSM).¹ The authors should be commended for moving beyond technical description toward an approach that integrates patient selection, surgical standardization, and outcomes assessment.

Minimally invasive NSM achieves oncologic outcomes comparable to conventional approaches, while offering advantages in aesthetic outcomes and early postoperative recovery.² However, despite these encouraging data, adoption remains heterogeneous and strongly influenced by system-level factors, including training, infrastructure, and access to technology. As a result, the central challenge is no longer feasibility alone, but safe, reproducible, and scalable dissemination across diverse clinical environments. In this context, the proposed framework is particularly valuable: the introduction of structured workflows, institutional checklists, and intraoperative “safety gates” represents an important step toward transforming E-NSM from an operator-dependent procedure into a traceable and auditable process.

While the framework presented by the authors addresses many of the structural barriers, an additional dimension warrants consideration: the intrinsic ergonomic limitations of conventional endoscopic instrumentation. As described, most centers implementing E-NSM rely on standard straight laparoscopic instruments. Although widely available, these tools impose technical constraints, particularly in anatomically confined regions. Limited triangulation, restricted degrees of freedom, and counterintuitive movements may increase operative difficulty and contribute to variability during the learning phase—factors that directly impact reproducibility.

This highlights a fundamental tension in minimally invasive breast surgery: approaches that are more accessible may be less ergonomic, while those that optimize ergonomics may be less accessible. Robotic platforms partially address these limitations through wristed instrumentation and improved maneuverability, but their cost and infrastructural requirements limit widespread adoption. Consequently, an important question arises: can reproducibility be achieved through structural frameworks alone, or does it also require addressing the technical constraints inherent to the procedure?

In our view, effective dissemination of E-NSM will require an integrated approach that combines institutional standardization with technical facilitation of surgical execution. In this context, we have recently reported the use of a handheld motorized articulating system in single-port endoscopic NSM, designed to overcome the limitations of straight laparoscopic instrumentation and facilitate dissection in anatomically constrained regions.³ Such approaches aim not to replace existing platforms, but to enable more consistent execution within established endoscopic workflows.

While structured workflows and training pathways are essential, their effectiveness ultimately depends on the ability to execute critical steps consistently. Our recent experience suggests that facilitating instrument angulation and control within confined operative fields may reduce technical variability, particularly during the learning phase, thereby supporting reproducibility in practice.

Ultimately, this work contributes to a necessary shift in perspective: from describing how E-NSM can be performed, to defining how it can be implemented, taught, and scaled safely. In this evolving landscape, technical solutions that enhance ergonomics within existing endoscopic frameworks may play an important complementary role in enabling broader dissemination. We congratulate the authors for a thoughtful and highly relevant contribution that provides a valuable foundation for the next phase of minimally invasive breast surgery.