Thyroid cancer is one of the most common malignancies worldwide, with its incidence steadily rising over recent decades, particularly among women aged 20-29 years (1–3). As the number of younger patients increases, there is a growing emphasis on both medical and aesthetic outcomes in treatment. Fortunately, thyroid cancer generally has a good prognosis with a high survival rate, making quality of life an important consideration for both patients and healthcare providers (4, 5).

Conventional open thyroidectomy (COT) remains a key treatment approach for thyroid cancer. However, one of its major drawbacks is the visible surgical scar on the anterior neck, which can be particularly prominent in patients prone to developing hypertrophic scars (6). This can lead to significant cosmetic concerns and psychological distress (7). Consequently, improving the aesthetic outcome of surgical scars, ensuring effective tumor control, enhancing postoperative recovery, and optimizing the patient’s quality of life have become critical objectives in thyroid cancer surgery.

Laparoscopic surgery has garnered increasing attention due to its numerous advantages, such as magnification, which allows for a clearer surgical field and improved precision during surgery. Furthermore, laparoscopic approaches typically involve smaller, less noticeable incisions, providing excellent cosmetic benefits while ensuring effective treatment outcomes (8–10). As a result, laparoscopic thyroidectomy has become increasingly popular among both thyroid surgeons and patients. Various laparoscopic approaches have been developed, including the Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and Gasless Unilateral Axillary Endoscopic Thyroidectomy (ETGUA) (11, 12). Each of these approaches has its own set of advantages and disadvantages, and there is still no consensus on which technique is the most suitable for clinical use. This study aims to compare the short-term and long-term outcomes of three surgical approaches for thyroid cancer: TOETVA, ETGUA, and COT.

Laparoscopic thyroidectomy has become a widely adopted surgical technique for treating thyroid cancer, offering several advantages over traditional open surgery (22–25). However, within the field of laparoscopic surgery, multiple approaches exist, each with distinct benefits and limitations. At our institution, laparoscopic thyroid surgery was first extensively implemented in 2020, which facilitated the development of expertise and the standardization of procedures. This study focused on patients who underwent surgery starting in 2022, thereby minimizing the impact of the learning curve, which could otherwise introduce bias into outcome comparisons (26, 27).

In this study, TOETVA was associated with the longest operative time among the three techniques. This can be attributed to the confined working space of the oral vestibule and the complex surrounding anatomy, which demands enhanced surgical precision. The restricted space limits instrument maneuverability, often resulting in challenging dissection and prolonged operation time (28–30). While prolonged operative time is a known risk factor for complications due to extended anesthesia exposure (31), and while the transoral approach converts a naturally clean (Class I) incision into a potentially contaminated (Class II) one—theoretically increasing infection risk—no statistically significant differences were observed in overall complication rates across the groups. This discrepancy can be explained by several factors. First, all three surgical techniques are well-established at our institution, with standardized procedures implemented since 2020, thereby minimizing the impact of the learning curve and ensuring consistency and proficiency in surgical execution. Second, strict perioperative protocols were uniformly applied, including aseptic techniques, continuous intraoperative monitoring, and systematic postoperative care, helping to mitigate risks associated with prolonged surgery. Additionally, the minimally invasive nature of TOETVA may itself reduce infection risk (29, 32, 33). Moreover, although TOETVA was the only approach in which prophylactic antibiotics were administered throughout the perioperative period, the standardized surgical and antiseptic protocols (such as strict aseptic techniques and consistent postoperative wound care) applied across all groups likely also contributed to maintaining low and comparable infection rates.

ETGUA was associated with the highest volume of postoperative drainage; however, there were no differences in the duration of drainage among the three groups. This technique involves creating a surgical access pathway through a subcutaneous tunnel from the axillary incision to the neck. The operative space is relatively spacious, the pathway is longer, and the procedure requires significant traction and dissection of surrounding tissues. These factors contribute to an increased accumulation of interstitial fluid postoperatively, resulting in greater drainage. The axillary incision site, which involves relatively thick skin and subcutaneous tissue, is also rich in blood vessels and lymphatic channels. The surgical manipulation in this area can disrupt these vessels, leading to fluid accumulation in the surgical region (34, 35). Although elevated drainage volumes are often indicative of greater tissue trauma and may theoretically increase the risk of seroma or delayed wound healing (36), no statistically significant differences were observed in rates of postoperative bleeding, incision infection, or chyle leakage among the groups. This suggests that the increased drainage did not correlate with a higher incidence of adverse clinical events. Furthermore, although TOETVA and ETGUA were associated with elevated WBC and CRP levels on POD1—reflecting a more pronounced initial inflammatory response likely due to more extensive dissection and access route establishment (37)—these values normalized by POD3. No significant intergroup differences were found in WBC, CRP, or IL-6 levels at that time. The absence of differences in IL-6, a sensitive and short-half-life marker of surgical stress (38, 39), further indicates that the inflammatory response was transient and well-controlled.

Previous studies have shown that while performing contralateral thyroid lobectomy via a unilateral axillary approach presents certain technical challenges, experienced surgeons have demonstrated that total thyroidectomy and bilateral central compartment lymph node dissection through a single axillary incision are feasible (40–43). However, in this study, ETGUA was associated with the fewest retrieved lymph nodes (LN). The limited visibility of the contralateral central compartment lymph nodes, due to obstruction from the trachea, larynx, and cricoid cartilage, restricts access to these nodes, leading to fewer lymph nodes being dissected. Therefore, in cases where contralateral lymph node enlargement is suspected, careful consideration should be given to the selection of ETGUA as the surgical approach.

In this study, TOETVA demonstrated the shortest incision length and the lowest VSS score, indicating the best scar appearance among the three surgical approaches. The moist environment of the oral cavity and its rich vascular supply contribute to rapid wound healing and scar fading. TOETVA utilizes a transoral approach, which avoids visible external incisions, offering excellent cosmetic outcomes (18, 44, 45). Interestingly, no significant difference in wound satisfaction was observed between TOETVA and ETGUA, despite TOETVA having the lowest VSS score. The ETGUA incision is located within the axillary fold, providing a concealed surgical site that does not affect the aesthetic result (46, 47).

In this study, we also evaluated the total hospital costs associated with TOETVA, ETGUA, and COT, as cost is an important factor in the selection of surgical techniques. No statistically significant differences were observed in total hospital costs among the three groups. This suggests that, despite differences in operative time and technical complexity, the overall financial burden of these procedures is comparable, making them equally viable options from a cost perspective when considering other clinical and cosmetic outcomes.

In this study, overall, no significant differences were observed between the groups in the dimensions of PF, RP, BP, GH, or VT. These dimensions reflect general physical health and functioning, suggesting that, despite the differences in surgical techniques, all three approaches may yield similar physical outcomes in the early postoperative period. However, TOETVA and ETGUA demonstrated superior long-term benefits in the SF, RE, and MH domains. Both TOETVA and ETGUA contributed to reduced visible scarring, which enhanced patients’ overall mental health and body image. These improvements may, in turn, promote better emotional well-being and self-esteem (48–50).

This study has several limitations. First, it was conducted at a single center, which may limit the generalizability of the results to other institutions or patient populations. Second, this study did not assess long-term recurrence or survival outcomes due to the relatively short follow-up period. Future studies with extended follow-up are needed to evaluate the oncological efficacy of TOETVA, ETGUA, and COT. Finally, while robotic surgery has become increasingly prevalent in clinical practice (51), our institution initiated robotic surgery relatively recently, having performed only 10 cases at the time of the study. To minimize potential bias associated with the learning curve effect, robotic surgery was excluded from this analysis.

Each surgical approach has its own advantages and limitations. TOETVA and ETGUA demonstrate superior outcomes in terms of incision satisfaction and specific dimensions of quality of life, providing significant benefits compared to COT. However, the selection of the surgical method should be individualized, considering both oncological effectiveness and the patient’s cosmetic and functional preferences.