Thyroid carcinoma is the most common endocrine malignancy, with its incidence continuing to rise globally (1, 2). Among its subtypes, papillary thyroid carcinoma (PTC) is the most prevalent (3). Surgical intervention remains the primary treatment modality for PTC. However, conventional thyroidectomy via anterior neck incision frequently results in noticeable scarring, which may be unacceptable for patients with high aesthetic expectations. Therefore, endoscopic thyroid surgery has been developed to address this concern. Common endoscopic approaches include trans-chest-breast, trans-axillary, transoral, and postauricular routes (4–6). However, these techniques frequently involve longer operative pathways and extensive flap dissection, resulting in increased hidden trauma. Moreover, some approaches require CO₂ insufflation, which may lead to complications (7). In recent years, gasless endoscopic thyroidectomy via the trans-subclavian approach has gained popularity in China due to its more discreet incision and shorter operating path. Despite its growing use, limited clinical data are available. This study retrospectively compares the outcomes of gasless endoscopic thyroidectomy via trans-subclavian approach and traditional open thyroidectomy performed at our hospital between February 2023 and August 2024 to evaluate the safety and effectiveness of this minimally invasive technique.

Traditional open thyroid surgery is commonly used due to its simplicity and effectiveness; however, it leaves a visible neck scar, which can cause psychological distress for patients. The rapid advancement of endoscopic thyroid surgery has made it a popular option among patients and doctors due to its more concealed incisions, which more effectively address patients’ cosmetic concerns (8). However, various endoscopic approaches come with their advantages and challenges. The chest-breast approach requires a longer surgical path and a larger area of subcutaneous dissection, resulting in more hidden trauma (9). Transoral endoscopic thyroid surgery, classified as a clean-contaminated procedure, carries a risk of deep neck infections and mental nerve injury, necessitating prophylactic antibiotics (10). Moreover, most approaches involve the infusion of CO₂ to establish an operating space, which may lead to complications such as CO₂ embolism, pneumothorax, subcutaneous emphysema, and hypercapnia (11, 12). The gasless axillary approach is more technically challenging than the subclavian approach due to its longer surgical path and interference from the sternum and clavicle (13).

The gasless subclavian approach for endoscopic thyroid surgery eliminates the need for CO₂ infusion, features a shorter surgical path, and enters through the natural space between the sternal and clavicular heads of the sternocleidomastoid muscle, resulting in less trauma and a concealed incision that aligns with patients’ cosmetic concerns. Our study revealed no significant differences between the subclavian endoscopic approach and traditional open thyroid surgery regarding the number of central lymph node dissections, intraoperative blood loss, drainage tube indwelling time, and postoperative complication rates (p>0.05). These findings suggest that the subclavian endoscopic approach provides comparable effectiveness and safety to traditional open surgery. In our study, one patient in the endoscopic group and two in the open group experienced temporary RLN injury, all of which recovered within three months postoperatively, likely due to intraoperative traction or edema. Only one patient (in the open group) developed permanent RLN paralysis due to tumor invasion of the RLN. Intraoperative nerve monitors effectively identified, exposed, and protected the RLN (14, 15). Gentle manipulation and avoiding traction on the nerve are crucial, and energy devices should be used at a safe distance to prevent thermal injury. None of the patients experienced postoperative bleeding, infection, chylous fistula, or hypoparathyroidism. Parathyroid glands should be preserved in situ during operation to prevent postoperative hypoparathyroidism. Using nanocarbon can assist in identifying the parathyroid glands (16), and parathyroid glands that are inadvertently resected or lack adequate blood supply should be promptly transplanted autologously.

Compared to traditional open thyroidectomy, the subclavian endoscopic approach considerably reduces postoperative neck discomfort (p<0.001), likely due to the preservation of the anterior cervical skin flap and fascia, maintaining the region’s anatomical integrity. Furthermore, the subclavian incision is well-concealed and easily covered by clothing, leading to higher patient satisfaction with the incision appearance (p<0.05). This approach does not prolong hospital stays or increase surgical costs (p>0.05), fulfilling cosmetic expectations without imposing additional financial burden.

This approach was frequently chosen by younger female patients, likely reflecting greater cosmetic concerns within this demographic. The endoscopic group exhibited longer operative times than the open group, possibly due to the need for subcutaneous tunnel creation and continuous adjustment of endoscopic retractors to maintain the operating space. The limited operative field and smoke generated by energy devices, such as ultrasonic scalpels, may further compromise endoscopic visibility and contribute to prolonged surgery duration. These factors collectively influence operative duration. Although the surgeon had prior endoscopic experience, some procedures in the endoscopic group were performed during the early phase of implementing gasless subclavian endoscopic thyroidectomy at our institution. This also increased the operation time of the endoscopic group to some extent. As the case volume increased, the surgical team became more proficient and coordinated, resulting in reduced operative times relative to the early phase. Further reductions in operative duration are anticipated with continued refinement and technical proficiency. The endoscopic group exhibited slightly higher 24-hour postoperative drainage than the open group, potentially due to a marginally extended skin flap dissection along the lateral neck and increased tissue trauma from the infraclavicular approach. Moreover, the open group benefited from direct visualization for precise vessel ligation. However, these factors did not prolong the drainage tube indwelling time.

The limitations of this study lie in relying solely on patients’ subjective perceptions to evaluate their satisfaction with postoperative incisions, lacking objective assessments. Additionally, the short follow-up period prevents the evaluation of the long-term outcomes of the subclavian endoscopic thyroidectomy. In future research, we will extend the follow-up duration and employ standardized scales to assess postoperative incision satisfaction and quality of life, further investigating the long-term efficacy of the subclavian endoscopic thyroidectomy.

In summary, subclavian endoscopic thyroidectomy offers a shorter surgical path and reduced trauma compared to other endoscopic approaches. Compared to traditional open surgery, it demonstrates comparable efficacy and safety, while significantly decreasing neck discomfort and meeting patients’ aesthetic expectations. It is economical, widely applicable, and merits broader clinical adoption. Although associated with slightly longer operative times and increased drainage, and mostly used for unilateral thyroid cancer treatment due to tracheal obstruction. These challenges are expected to diminish with ongoing surgical improvements.