Controversies in remote access thyroid surgery

Remote-access thyroidectomy comprises a group of endoscopic and robotic procedures, including the bilateral axillo-breast, gasless axillary, retroauricular, and transoral vestibular approaches, developed to relocate or conceal the cervical incision while maintaining operative efficacy. This review summarizes current evidence regarding safety, oncologic adequacy, cosmetic outcomes, learning curve, cost, and patient selection. Across multiple meta-analyses, rates of recurrent laryngeal nerve injury and hypoparathyroidism are comparable to conventional open thyroidectomy in appropriately selected patients. However, results vary with technique and surgeon experience. Each approach introduces specific risks, including mental nerve injury in transoral cases, brachial plexus symptoms and anterior chest dysesthesia in axillary or breast routes, and greater auricular neuropathy following retroauricular dissection. Rare complications such as CO2 embolism and pneumomediastinum have also been reported. Current oncologic data are primarily observational. Existing guidelines limit remote-access procedures to low-risk, well-differentiated carcinomas that do not require central or lateral neck dissection. Cosmetic satisfaction tends to be greater in the early postoperative period, while differences diminish over time. Operative duration remains longer and costs higher than open thyroidectomy, primarily due to equipment and operating room time. Remote-access thyroidectomy should be offered selectively to motivate patients who prioritize cosmetic outcomes and be performed by high-volume surgeons with dedicated training. Further prospective studies are needed to clarify long-term oncologic safety, cost-effectiveness, and quality-of-life outcomes.