Endoscopic thyroidectomy - Is it safe and reliable? - Experience and results at a tertiary care centre in India

Minimal access thyroidectomy can be performed using several approaches, including transaxillary, breast-axilla and transoral endoscopic thyroidectomy (ET) vestibular approach (TOETVA). These techniques are designed to minimise visible scarring and enhance cosmetic outcomes. Endoscopy allows magnification, enabling improved visualisation of the recurrent laryngeal nerve (RLN) and parathyroid glands.

This retrospective study evaluates the safety, reliability and complication rates of ET and proposes criteria for selecting the optimal approach. 266 patients who underwent minimal access thyroidectomy from May 2016 to May 2025 were included. Fine-needle aspiration cytology indicated benign aetiology (Bethesda Class 2) in 171 patients, indeterminate aetiology (Bethesda Class 3 and 4) in 71 patients and 24 patients were highly suspicious or proven malignancy (Bethesda Class 5 and 6). The primary indication was a solitary thyroid nodule (STN) in 204 patients, multinodular or bilobar lesions in 62 patients and malignancy in 24 patients.

TOETVA was performed in 227 patients (nodule sizes 2-6 cm, 86% <4 cm), unilateral transaxillary thyroidectomy in 31 patients (STN, 4-6 cm) and bilateral transaxillary thyroidectomy in 8 patients multinodular goitre [MNG], 4-6 cm). TOETVA had the shortest mean operative time (67.3 min), lowest blood loss and shortest post-operative hospital stay (mean 2.31 days). RLN identification was above 96% in all approaches owing to better magnification. Transaxillary approach was associated with more RLN paresis than the TOETVA approach (4.85% vs. 16.13%; P = 0.002). Parathyroid identification without adjuncts was 91.6%, 80.64% and 62.5%, respectively, with three approaches. No patients had permanent hypocalcaemia with the TOETVA approach, which was significantly better in total thyroidectomy cases than the bilateral transaxillary approach. 16.13% and 25% of patients had seroma with unilateral and bilateral transaxillary approach, respectively, despite drain placement, which accounted for longer hospital stay.

ET is safe and reliable with appropriate patient selection and has a skilled endoscopic surgeon. The approach selection depends on the size of the nodule and the surgeon comfort and preference. However based on our study results and experience we recommend the following:STN/MNG <4 cm: TOETVA STN 4-6 cm: Unilateral transaxillary approach MNG 4-6 cm: Bilateral transaxillary approach.