Awake endoscopic mastectomy in one-day-surgery: Preliminary results

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BACKGROUND: While enhanced recovery after surgery (ERAS) and awake monitored anaesthesia care (MAC) have been described to promote same-day discharge (SDD) in conventional mastectomy, their application in reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) has not yet been established. We present our protocol and early experience with awake R-E-NSM. METHODS: In this retrospective pilot case series, from February 2026 to April 2026, all consecutive awake R-E-NSM performed at Tor Vergata University Hospital were retrieved from a prospectively maintained database (Approval number 62.25CET2-PTV) and reported according to the PROCESS guidelines. Eligible women were aged 18-70 years with cT0-2 cN0-1 breast cancer or known pathogenic genetic variants, scheduled for prepectoral reconstruction. Awake MAC was achieved through an opioid-free combination of ultrasound-guided regional anaesthesia. Primary outcomes of this preliminary analysis were the SDD rate and conversion to general anaesthesia (GA); secondary outcomes included operative time, postoperative length of stay (LOS), time to mobilisation, pain at rest (PAR) and movement-evoked pain (MEP), calculated with 48-h area under the curve (AUC) on numerical rating scale (NRS). RESULTS: 12 awake R-E-NSM were performed in 10 patients, with a median age of 44.3 (38.7-69.2) years. No GA conversion was required. Surgical conversion for oncological reasons occurred in 2/12 (16.7%) cases. Median operative time was 210 (119-315) minutes. Median LOS was 12.0 (8.0-72.0) h; SDD was achieved in 9/10 (90%) patients, with discharge eligibility criteria met at 6 h. Median mobilisation time was 53.9 (24.6-115.1) minutes. PAR and MEP AUC were 196 (112-368) and 208 (132-382) NRS·h, respectively. The overall 30-day complication rate was 2/12 (16.7%), including one reoperation (NAC necrosis reoperation, 1/12, (8.3%) without implant loss. CONCLUSIONS: Awake R-E-NSM can be safely managed within an SDD protocol, with favourable early postoperative outcomes. Further studies are warranted to determine the impact of ERAS protocol on R-E-NSM.

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