Comparison of transoral and bilateral axillo-breast approach endoscopic thyroidectomy: multicentre study

Remote-access thyroidectomy techniques such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and bilateral axillo-breast approach (BABA) offer cosmetic advantages, yet multicentre evidence comparing perioperative safety, operative efficiency, and histopathological integrity is limited.

This retrospective multicentre cohort study included consecutive adult patients who underwent TOETVA or BABA at four tertiary referral centres between 1 January 2020 and 31 December 2022. Surgeons had surpassed the learning curve. Propensity score matching (1 : 1) was performed based on demographic and clinical variables. Patients with < 12 months follow-up were excluded. Data on operative time (total and phase-specific), postoperative pain, complications, specimen integrity (fragmentation and capsule status), length of hospital stay, reoperations, and mid-term outcome measures, including recurrence, were collected.

For 507 eligible patients (TOETVA, 216; BABA, 291), matching achieved balanced baseline characteristics. TOETVA had longer operative time than BABA (125.6 versus 97.7 minutes; P < 0.001), with faster flap creation but slower thyroidectomy. Complication rates were similar for TOETVA and BABA, including vocal cord palsy (1.1% versus 2.8%, respectively) and hypoparathyroidism (2.2% versus 3.3%, respectively). TOETVA had higher rates of specimen disruption (12.8% versus 6.1%; P = 0.031), whereas tumour capsule integrity was comparable. Bilateral thyroidectomy independently prolonged operative time in both groups; tumour size and male sex also increased operative time in BABA. Mid-term recurrence was uncommon, although recurrence after BABA more often required open or chest wall incisions, whereas recurrence after TOETVA was managed through a limited cervical approach.

TOETVA and BABA are safe and effective remote-access thyroidectomy options, each with distinct technical considerations. TOETVA offers a scarless mid-line corridor with less postoperative discomfort but carries a higher risk of specimen disruption, whereas BABA provides broader exposure and shorter thyroidectomy time but is more affected by anatomical and tumour factors. These findings support evidence-based surgical planning and individualized patient counselling.