Endoscopic Axillary Lymphadenectomy in Breast Cancer: Evolution, Current Evidence, and Future Perspectives

Axillary lymph node staging remains a cornerstone of the surgical management of breast cancer. Conventional axillary lymph node dissection (ALND) has historically been the standard procedure for evaluating nodal involvement; however, it is associated with significant morbidity, including lymphedema, sensory disturbances, and reduced shoulder mobility. Over the past few decades, minimally invasive surgery has demonstrated clear benefits in multiple surgical fields, particularly in reducing postoperative morbidity, improving recovery, and enhancing cosmetic outcomes. In breast surgery, these principles have been progressively incorporated into clinical practice. Endoscopic techniques were first introduced in the late 1990s as a minimally invasive alternative to axillary lymph node dissection. Early studies have demonstrated the technical feasibility of endoscopic axillary lymphadenectomy (EALND), reporting adequate lymph node retrieval and acceptable perioperative outcomes. Although the widespread adoption of sentinel lymph node biopsy and the progressive de-escalation of axillary surgery have limited the diffusion of this approach, the potential advantages of minimally invasive techniques appear to be applicable to axillary surgery. In recent years, minimally invasive approaches, including endoscopic and robot-assisted procedures, have been expanded in breast surgery and are now being explored for axillary management. Advances in instrumentation, optics, and imaging technologies, such as fluorescence, have improved surgical visualization and may facilitate safer and more precise dissection of axillary structures. This review summarizes the historical development, technical evolution, and current evidence regarding endoscopic axillary lymphadenectomy for breast cancer. Furthermore, we discuss the potential role of this approach in the modern era of axillary de-escalation and highlight the emerging technologies that may contribute to the future development of minimally invasive axillary surgery.