Robotic and endoscopic minimally invasive breast surgery: a narrative synthesis on divergent global adoption and...

Minimally invasive breast surgery (MIBS), encompassing robotic-assisted and endoscopic approaches, has gained increasing attention as an alternative to conventional breast surgery, aiming to optimize cosmetic outcomes while maintaining oncologic safety. To date systematic reviews and meta-analyses have evaluated perioperative and oncologic outcomes, but with minimal understanding and emphasis on how these techniques are adopted globally and how health-system factors influence their dissemination. This narrative review synthesizes evidence from published clinical series, comparative studies, systematic reviews, and consensus statements reporting robotic or endoscopic breast surgery. Studies were contextualized according to World Bank income classifications. Trends were analyzed qualitatively with respect to operative platforms, access strategies, reconstruction integration, training pathways, and cost and resource considerations. MIBS represents a heterogeneous group of procedures rather than a single standardized intervention. Globally nipple-sparing mastectomy with immediate implant-based reconstruction is the most commonly reported application. In high-income countries, adoption has been predominantly robotic-driven, facilitated by access to advanced platforms, institutional investment, and multidisciplinary reconstructive services. Upper-middle-income countries especially East Asia have emerged as global leaders in endoscopic breast surgery, favoring scalable, cost-conscious approaches integrated with refined workflows. In contrast, adoption in lower-middle- and low-income settings remains limited and selective, shaped by infrastructure constraints, training gaps, and competing public health priorities. MIBS has evolved along divergent global trajectories driven not only by technical feasibility but increasingly by system-level determinants. Understanding these income-stratified trends is essential for contextualizing existing evidence, guiding equitable dissemination, and informing future research and guideline development tailored to diverse healthcare environments.