Modified Gasless Endoscopic Total Thyroidectomy via a Unilateral Subclavian Approach for Papillary Thyroid Carcinoma

Modified Gasless Endoscopic Total Thyroidectomy via a Unilateral Subclavian Approach for Papillary Thyroid Carcinoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Modified Gasless Endoscopic Total Thyroidectomy via a Unilateral Subclavian Approach for Papillary Thyroid Carcinoma Gaofei He, Nizhen Xu, Jinxi Jiang, Junjie Chu, Xiaoxiao Lu, Deguang Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6372469/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract To evaluate the technical feasibility and surgical outcomes of modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach for treating papillary thyroid carcinoma. A retrospective analysis of the clinical data of 117 patients with papillary thyroid carcinoma who underwent modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach at the Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, from March 2022 to June 2024 was conducted. All surgeries were successfully completed endoscopically without conversion to open surgery. The mean tumour size was 8.4±4.7 mm, and the mean operative time was 154.2±32.4 minutes. The mean number of harvested central compartment lymph nodes was 12.4±6.6, and the mean length of postoperative hospital stay was 3.2±1.1 days. Postoperative complications included temporary hypoparathyroidism (n=6, 5.1%), temporary hoarseness (n=3, 2.6%), and postoperative haemorrhage (n=2, 1.7%). All temporary complications resolved spontaneously within three months. No permanent recurrent laryngeal nerve（RLN）palsy, permanent hypoparathyroidism, or incision infection occurred. During the follow-up period, one patient developed lateral neck lymph node recurrence at 13 months postoperatively and subsequently underwent bilateral neck dissection. Modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach demonstrated feasibility in carefully selected patients. This technique enables comprehensive central compartment lymph node dissection while preserving anterior cervical function, suggesting its potential clinical applicability. Biological sciences/Cancer/Endocrine cancer/Thyroid cancer Health sciences/Endocrinology/Endocrine system and metabolic diseases/Thyroid diseases Endoscopy Papillary thyroid carcinoma Subclavian approach Total thyroidectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction Shimizu et al. first reported the use of the subclavian approach for endoscopic thyroid surgery in 1998 [1] .Based on extensive clinical experience and surgical expertise, our team has systematically refined conventional subclavian endoscopic thyroidectomy through strategic modifications, including optimized incision placement, a modified surgical approach, and innovative instruments [2] .These innovations have resulted in a modified approach characterized by cosmetically advantageous incision placement, superior preservation of anterior cervical function [3] , reduced technical complexity, and improved thoroughness of central lymph node dissection. Although this surgical technique has proven particularly effective for unilateral thyroid malignancies, the application of bilateral total thyroidectomy through a unilateral incision remains challenging, primarily because the trachea creates a substantial anatomical barrier, limiting surgical access to the contralateral thyroid gland and lymph nodes. Since March 2022, our team has successfully implemented a novel unilateral subclavian approach for bilateral thyroid procedures, achieving promising preliminary outcomes. This study systematically evaluated the technical innovations and clinical feasibility of this refined surgical approach. Materials and Methods A retrospective analysis was conducted on patients treated with modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach for papillary thyroid carcinoma at Sir Run Run Shaw Hospital affiliated with Zhejiang University School of Medicine from March 2022 to June 2024. The cohort included 6 males and 111 females, with a mean age of 39.7 ± 11.0 years (range: 21–66 years). Data on primary tumour size, surgery duration, postoperative complications, hospitalization time, number of central lymph nodes dissected, and follow-up measurements, including thyroglobulin level and ultrasonography of the thyroid area and neck, were recorded. All surgeries were performed in accordance with the Guidelines for the diagnosis and treatment of thyroid nodules and differentiated thyroid cancer (the second edition) by the same team. The collection of clinical data was approved by the Ethics Committee of Sir Run Run Shaw Hospital after informed consent was written by each patient. Surgical Instruments The surgical instruments used in this study included standard endoscopic thyroid surgery instruments and custom-developed tools. (1) Standard instruments consisted of a 30°, 10-mm diameter high-definition endoscope with a camera unit, endoscopic grasping forceps, endoscopic separating forceps, an endoscopy suction device(KARL STORZ, Germany), and a 36-cm ultrasonic scalpel(Johnson & Johnson, USA). (2) Custom-developed instruments comprised two suspension hooks with suction tubes, each of different lengths 10 cm and 12 cm)(Fig. 1). Inclusion and Exclusion Criteria The inclusion criteria were as follows: (1) papillary thyroid carcinoma confirmed by preoperative ultrasound-guided fine-needle aspiration biopsy, with a maximum tumour diameter ≤3 cm and the absence of lateral cervical lymph node metastasis; (2) surgical procedure including bilateral thyroid lobectomy plus unilateral or bilateral central neck dissection; and (3) no previous history of neck surgery or radiation therapy. The exclusion criteria were as follows: (1) preoperative evidence of primary tumour or lymph node invasion into adjacent structures (trachea, oesophagus, larynx, or recurrent laryngeal nerve);(2) a tumour in the contralateral gland located close to the entry point of the larynx of the recurrent laryngeal nerve(RLN); and (3) a history of keloid formation or a known predisposition to keloid scarring. Operative Techniques The patient was placed in a supine position with a shoulder roll, with the head slightly extended and turned towards the contralateral side.General anaesthesia was administered via oral intubation using a nerve-monitoring endotracheal tube（Medtronic, USA）. The anaesthesia stand was fixed between the contralateral axillary apex and shoulder midpoint to facilitate cavity suspension. After the operative area was sterilized and draped, the assistant was positioned at the head side, the main surgeon at the foot side, and the instrument table and scrub nurse at the head side(Fig. 2). An incision, approximately 3–4 cm in length, was marked along the subclavian skin line, just below the clavicle, between the anterior border of the sternocleidomastoid muscle(SCM) and the posterior border of the sternum(Fig 3). Dissection of the anterior neck region was carried out by layer under the platysma using electric cautery under direct vision. After the clavicular and sternal branches of the SCM were exposed, the space between these two branches was separated, and a modified retractor was placed to lift the clavicular branches(Fig 4). The strap muscles were exposed and dissected laterally by a Harmonic scalpel (Johnson & Johnson, Cincinnati, Ohio, USA) under endoscopic guidance. The thyroid cavity was then created by lifting the strap muscles with the retractor, allowing for dissection of the thyroid gland. The thyroid gland and the strap muscles were lifted together using the retractor. The RLN was exposed at the level of the inferior thyroid pole and dissected upwards to its entry point into the larynx, with continuous intraoperative nerve monitoring [4] . Central compartment lymph node dissection was performed along with thyroidectomy. When the superior pole region of the thyroid gland was approached, care was taken to preserve the parathyroid gland in situ as much as possible. The upper pole of the thyroid gland was drawn downwards, and the superior thyroid vessels were identified via nerve monitoring and then divided close to the thyroid gland using a Harmonic scalpel to protect the external branch of the superior laryngeal nerve (EBSLN).The thyroid gland was then retracted medially, and careful dissection was performed to divide the Berry ligament to complete the ipsilateral thyroidectomy(Fig 5). After specimen removal, the patient's head was turned, and the surgical bed was adjusted towards the operating side to facilitate elevation of the contralateral thyroid gland（Fig 6）. An endoscopic suction device was used to push down the trachea, allowing further separation of the thyroid from the tracheal tissue up to the contralateral edge(Fig 7). The retractor was then moved to the inferior pole region of the cavity, and dissection was performed laterally along the trachea to identify the contralateral RLN under continuous nerve monitoring. After the nerve was isolated, the inferior pole of the thyroid was elevated to expose the RLN up to the point of entry into the larynx. The dissection continued downwards to the level of the brachiocephalic trunk and extended laterally to expose the contralateral carotid sheath, which served as the lateral boundary for central neck dissection. The inferior parathyroid glands were preserved in situ whenever possible. In cases where preservation was not feasible or the vascular supply was compromised, immediate parathyroid gland autotransplantation was performed [5] . Following completion of the inferior pole dissection, the retractor was moved to expose the superior pole region of the thyroid. Dissection was performed along the cricothyroid space towards the superior pole, while the EBSLN was identified and protected under continuous nerve monitoring. The superior pole vessels were then gradually severed. The superior pole was pulled medially and downwards, while dissection proceeded along the lateral border of the thyroid gland down to the cricothyroid muscle level. After both superior and inferior pole dissections were completed, the thyroid gland was pulled laterally. Endoscopic suction was used to push down the trachea, creating additional working space for meticulous dissection of the gland. The Berry’s ligament was carefully dissected and divided in a stepwise fashion. The RLN and superior parathyroid gland were meticulously dissected from the thyroid gland. Finally, the contralateral thyroid gland and contralateral central compartment specimens were removed as en blocs (Fig. 8).The resected specimens were carefully examined for any parathyroid glands, with immediate autotransplantation performed if identified. Serum parathyroid hormone (PTH) and calcium levels were measured on postoperative day one to assess parathyroid function. Hypoparathyroidism was defined as a decrease in PTH to the lower limit of the normal range, necessitating calcium supplementation for symptom control. If hoarseness occurred postoperatively, laryngoscopy was performed to assess vocal cord mobility. Hypoparathyroidism and RLN palsy were classified as permanent complications if they remained unresolved within 6 months. Results All 117 patients underwent successful endoscopic surgery without conversion to open surgery. 17 patients underwent total thyroidectomy with unilateral central compartment dissection, and 100 patients underwent total thyroidectomy with bilateral central compartment dissection (Table 1).The mean operation time was 154.2±32.4 minutes (range: 85–240 minutes), with a mean intraoperative blood loss of19.0±11.2 mL (range: 5–100 mL). Specifically, the mean intraoperative blood loss volume was 17.7±7.52 mL (range: 10–30 mL)for total thyroidectomy with unilateral central compartment dissection and 19.2±11.7 mL (range: 5–100 mL)for bilateral central compartment dissection. The mean postoperative drainage volume was 137.3±58.8 mL (range: 30–420 mL), with 128.53±36.6 mL (range: 80–212 mL) for unilateral central compartment dissection and 138.8±61.8 mL (range: 30–420 mL)for bilateral dissection. The mean postoperative hospital stay was 3.2±1.1 days (range: 2–7 days). The mean maximum diameter of papillary thyroid carcinoma was 8.4±4.7 mm (range: 3–25 mm), with a mean of 12.4±6.4 harvested central compartment lymph nodes (range: 0–30) and 1.5±2.1 metastatic lymph nodes (range: 0–10). Postoperative pathological staging included 87 cases of pT1a, 23 cases of pT1b, 5 cases of pT2, and 2 cases of pT3b. There were 51 cases of pN0 and 66 cases of pN1a(Table2).Postoperative transient hypoparathyroidism occurred in 6patients, which resolved by the one-month follow-up. Transient recurrent laryngeal nerve injury occurred in 3patients, all of whom were resolved by the three-month follow-up. There were 2 cases of postoperative bleeding managed by haematoma evacuation through the original subclavian incision, with satisfactory recovery. There were no instances of permanent RLN, permanent hypoparathyroidism, or infections. One month post surgery, all the incisions had healed well, with satisfactory cosmetic results. Patients were followed for 3–15 months postoperatively, with a mean thyroglobulin level of 0.31±0.58ng/mL (range: 0–3.56 ng/mL). Ultrasound examination of the thyroid and cervical lymph nodes six months post surgery revealed no local recurrence or metastasis. One patient experienced lateral neck lymph node recurrence 13 months after surgery and underwent a second bilateral neck lymph node dissection. Discussion Over the past decade, various techniques for endoscopic thyroid surgery have been introduced [6-12] . Shimizu et al. [1] first reported endoscopic thyroid surgery via the subclavian approach in 1998, which allows for unilateral thyroidectomy, near-total thyroidectomy, and total thyroidectomy. During the procedure, a 3–4 cm incision is made in the chest wall skin beneath the clavicle, which can be covered by clothing. For bilateral thyroid surgery, extensive dissection of the anterior neck and chest wall via the midline cervical approach is needed. Our team improved the traditional subclavian endoscopic thyroid surgery by optimizing incision placement, surgical pathways, and instruments [2] . Compared with other techniques, the trans-subclavian approach features a shorter surgical path, requiring less flap separation during the establishment of the surgical space, which significantly reduces trauma to patients and relieves skin numbness. This approach also provides a concealed incision, better preservation of anterior neck function, lower operational difficulty, and thorough central compartment dissection, making it particularly suitable for unilateral thyroid cancer surgery. The subclavian approach is similar to axillary endoscopic thyroid surgery, both of which utilize a lateral approach. Owing to obstruction by the trachea, conventional endoscopic instruments cannot access the entire thyroid, and exposure of the contralateral thyroid, particularly at the entry point of the RLN into the larynx, is challenging. Additionally, the limited operating space results in significant leverage effects during instrument manipulation, causing traction on the gland. To protect the RLN, there is a tendency to leave residual thyroid tissue at the point of laryngeal entry, making contralateral thyroid surgery more difficult. This approach has been attempted by a few centres both domestically and internationally. While steerable robotic arms make total thyroidectomy feasible, sufficient working space must be created for comfortable movements of the robotic arms [13] . Moreover, robotic surgery can be expensive and is not universally available. In this study, our team improved the surgical procedure by analysing the anatomical structure of the contralateral thyroid and lymph nodes and considering the advantages of the subclavian approach, which involves shorter tunnels and fewer operational constraints. First, to fully expose the contralateral gland, the patient's head is turned to the ipsilateral side, and the operating table is tilted towards the same side, making the contralateral thyroid gland more superficial and easier to manipulate. Second, to create more visual space, we removed the ipsilateral thyroid gland before resecting the contralateral thyroid lobe. During contralateral surgery, the operating space is limited; however, by appropriately adjusting the retractor, the space can be shifted towards the target operation site, such as by moving the retractor cranially for superior pole dissection or caudally for increased space at the inferior pole. The space between the contralateral thyroid and the strap muscle is not separated prematurely; instead, the entire contralateral thyroid lobe is lifted with the strap muscle by the retractor. If necessary, the retractor can be positioned beneath the contralateral thyroid lobe for elevation, facilitating posterior dissection. An endoscopic suction device can also be inserted into the surgical field, using the skin incision as a fulcrum to depress the trachea medially, thereby creating symmetrical traction and providing adequate space for separation. Owing to the limited symmetrical traction in the endoscopic thyroid, preservation of the inferior parathyroid gland in situ becomes challenging. The parathyroid glands located within the thymus and those with an intact blood supply should be preserved in situ as much as possible. Any parathyroid glands that are inadvertently excised with the thyroid specimen or compromised by vascular supply should be identified in resected specimens and considered for immediate autotransplantation. In the process of RLN dissection, the nerve is first identified at the inferior pole of the thyroid and dissected superiorly to its entry point into the larynx. The superior pole is then dissected through the space between the cricothyroid ligament, with downwards traction of the gland to increase mobility. After the inferior and superior poles of the thyroid are separated, the surrounding tissue at the point where the RLN enters the larynx is dissected close to the gland. The RLN and superior parathyroid gland are then released to complete the removal of the contralateral thyroid gland. This method results in no significant residual tissue in the laryngeal entry area, requires less time for nerve separation and protection, and simplifies the operative procedure. The point where the RLN enters the larynx is the most challenging area for surgical operation, necessitating preoperative assessment. When a tumour is located in this area, careful consideration should be given to either accessing from that side or selecting an alternative surgical approach. Given the relative difficulty in handling the contralateral thyroid, the incision can be appropriately extended in the early stages of implementing this approach to facilitate subsequent operations. In this study, 35 cases were treated via a left-sided approach, and 82 cases were treated via a right-sided approach, with comparable operative times for the contralateral approach. However, during left-sided approaches, interference between the primary surgeon and the endoscope-holding assistant was more frequent, likely because all surgeons in this study were right-handed and because the assistant holding the endoscope was positioned on the right side of the primary surgeon. Therefore, when bilateral thyroid tumours are comparable in size and characteristics, a right-sided approach may be preferable to reduce operational difficulty. Compared with open neck surgery, incisions for subclavian endoscopic thyroid surgery can be concealed with clothing, offering better aesthetic results and greater patient acceptance(Fig 9). Compared withother endoscopic approaches for total thyroidectomy, this approach minimizes subcutaneous tunnelling, thereby significantly reducing operative complexity. In this study, the mean intraoperative blood loss was only 19.0±11.2 mL, the postoperative drainage volume was 137.3±58.8 mL, and the mean length of postoperative hospital stay was 3.2±1.1 days, demonstrating both safe intraoperative procedures and rapid postoperative recovery. Histopathological examination revealed that an average of 12.4±6.6 central compartment lymph nodes were dissected, with 1.5±2.1 metastatic lymph nodes, demonstrating thorough tumour and lymph node clearance. This approach retains the advantages of a gasless endoscopic approach, eliminating insufflation-related CO 2 complications. During cavity creation, anterior neck flap dissection is minimal, the cavity is formed quickly, and the subcutaneous tunnel is short, reducing operational constraints and difficulty, with a high rate of complete exposure in the central compartment [17]. Additionally, this approach enables bilateral thyroidectomy via the intermuscular plane of the SCM, resulting in enhanced postoperative sensory and swallowing functions while preserving anterior neck functionality. This approach utilizes the subclavian retractor device developed by our team, which requires simple equipment and has low surgical costs. Compared with the transoral vestibular approach for bilateral thyroidectomy, the limitation of the unilateral subclavian approach is that subclavian scars remain postoperatively, making it unsuitable for patients with keloid-prone skin. However, this approach avoids the potential infection risks associated with the transoral vestibular approach. Given proper indications, gasless endoscopic total thyroidectomy via the unilateral subclavian approach is safe and feasible, achieving thorough tumour resection with optimal incision concealment and demonstrating significant clinical value. However, given the limited sample size of this study, further large-scale, multicentre clinical trials are warranted to validate the efficacy and applicability of this surgical approach in thyroid cancer treatment. Declarations Data availability statement The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References Kazuo Shimizu 1, Wataru Kitagawa, Haruki Akasu, et al. Video-assisted minimally invasive endoscopic thyroid surgery using a gasless neck skin lifting method--153 cases of benign thyroid tumors and applicability for large tumors[J].Biomed Pharmacother . 2002;56 Suppl 1:88s-91s. https://doi: 10.1016/s0753-3322(02)00239-1 Jinxi, J, Gaofei He, et al. Single-incision gasless trans-subclavian endoscopic approach thyroidectomy. Updates Surg (2024). https://doi: 10.1007/s13304-024-01948-7 Jandee,L, In, et al. Comparative analysis of oncological outcomes and quality of life after robotic versus conventional open thyroidectomy with modified radical neck dissection in patients with papillary thyroid carcinoma and lateral neck node metastases.[J].Journal of Clinical Endocrinology & Metabolism, 2013. https://doi:10.1210/jc.2013-1583. Dralle H, Sekulla C, et al. German IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008 Jul;32(7):1358-66. https://doi: 10.1007/s00268-008-9483-2 Zhang D, Gao L, et al. Predictors of graft function after parathyroid autotransplantation during thyroid surgery[J]. Head Neck, 2018, 40(11):2476-2481. https://doi: 10.1002/hed.25371 Huscher CS , Chiodini S , et al. Endoscopic right thyroid lobectomy . Surg Endosc 11:877. https://doi: 10.1007/s004649900476 Ikeda Y , Takami H , Sasaki Y ,et al.Endoscopic resection of thyroid tumors by the axillary approach[J].Journal of Cardiovascular Surgery, 2000, 41(5):791-2. https://doi :10.1177/106689690000800421. Ohgami M , Ishii S , Arisawa Y ,et al.Scarless endoscopic thyroidectomy: breast approach for better cosmesis.[J].Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 2000, 10. https://doi:10.1097/00129689-200002000-00001. Ikeda Y, Takami H, et al. Total endoscopic thyroidectomy: axillary or anterior chest approach. Biomed Pharmacother. 2002;56 Suppl 1:72s-78s. https://doi: 10.1016/s0753-3322(02)00274-3. L ee KE, Kim HY, et al. Postauricular and axillary approach endoscopic neck surgery: a new technique. World J Surg. 2009 Apr;33(4):767-72. https://doi: 10.1007/s00268-009-9922-8. Anuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. World J Surg. 2016 Mar;40(3):491-7. https://doi: 10.1007/s00268-015-3320-1. Jinxi J , Gaofei He, et al. Novel suspension system for gasless transoral vestibular thyroidectomy. Surg Endosc. 2023 Feb;37(2):1070-1076. https://doi: 10.1007/s00464-022-09528-9. Kim M J , Nam K H , Lee S G ,et al.Yonsei Experience of 5000 Gasless Transaxillary Robotic Thyroidectomies[J].World Journal of Surgery, 2018. https://doi:10.1007/s00268-017-4209-y. Tables Table1 Demographic and clinical data of study population (n=117) Variables Value Range/percent Age 39.7±11.0 21~66 Gender Male 6 5.1% Female 111 94.5% Extent of surgery TTUCND 17 14.5% TTBCND 100 85.5% TTUCND，total thyroidectomy with unilateral CND； TTBCND, total thyroidectomy with bilateral CND Table 2 Surgical outcomes of gasless endoscopic thyroidectomy via modifed trans-subclavian approach (n=117) Variables Value Range/percent Pathology Tumor size（mm） 8.3±4.7 3~25 T stage pT1a 87 74.4% pT1b 23 19.7% pT2 5 4.3% pT3 2 1.8% N stage Pn0 51 43.6% Pn1a 66 56.4% Operative time(min) 154.2±32.4 85-240min No. of dissected LNs 12.4±6.6 0~35 No. of LNs metastasis 1.5±2.1 0~10 Postoperative hospital stay（d） 3.2±1.1 2-7d Complications Transintvocal cord palsy 2 Transinthypoparathyoidism 6 Recurrence 1 Hematoma 2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Oct, 2025 Reviews received at journal 05 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviewers agreed at journal 28 Sep, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 11 Apr, 2025 Editor invited by journal 11 Apr, 2025 Submission checks completed at journal 10 Apr, 2025 First submitted to journal 03 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6372469","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":524871814,"identity":"65acdae3-bc2f-47bf-b3f4-22f44a7adf9f","order_by":0,"name":"Gaofei He","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gaofei","middleName":"","lastName":"He","suffix":""},{"id":524871815,"identity":"9af7b5f0-ec45-4f7d-90e4-553678ad4b4b","order_by":1,"name":"Nizhen Xu","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nizhen","middleName":"","lastName":"Xu","suffix":""},{"id":524871816,"identity":"68b4baaa-e1f7-443a-bbfb-65ac4f9a0e2c","order_by":2,"name":"Jinxi Jiang","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jinxi","middleName":"","lastName":"Jiang","suffix":""},{"id":524871817,"identity":"437ad78a-d382-4476-8f81-291534b38e4d","order_by":3,"name":"Junjie Chu","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":false,"prefix":"","firstName":"Junjie","middleName":"","lastName":"Chu","suffix":""},{"id":524871818,"identity":"bb54be46-2811-4cdc-a0de-f45dcd00b74e","order_by":4,"name":"Xiaoxiao Lu","email":"","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxiao","middleName":"","lastName":"Lu","suffix":""},{"id":524871819,"identity":"83b88cca-5e43-4c5e-83e3-7fe5789d3b18","order_by":5,"name":"Deguang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBACeYaDjQ8SKmzkGBgOALlsRGgxbDx82ODDmTRj4rUwHD6WJjmz7VBiA5hHjBbGtjNm0jxnDqTPbzxjwPCh7DAD/+wG/FrYec4YW/NU3MltbDhjwDjj3GEGiTsHCNgy44zhbZ4zz3KbGc4YMPO2HWYwkEgg4LL7bwykgSrT2UBa/hKl5cCxJKD3DyfwgLQwEqPFsAESyIYzGI4VHOw5l84jcYOAFlhUysvPOLzxwY8yazn+GYQcBgcSB8CRyUOseiDgbyBB8SgYBaNgFIwoAAASdU2ckkPu5QAAAABJRU5ErkJggg==","orcid":"","institution":"Sir Run Run Shaw Hospital","correspondingAuthor":true,"prefix":"","firstName":"Deguang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-04-04 00:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6372469/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6372469/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93018701,"identity":"aea37e69-7a3c-4d39-940d-4bf55eb8b9f0","added_by":"auto","created_at":"2025-10-08 08:24:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55987,"visible":true,"origin":"","legend":"\u003cp\u003eTwo self-developed retractors of diferent lengths ( A,10 cm, for ipsilateral thyroidectomy, and B,12 cm, for contralateral thyroidectomy)\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/6b18fa09871806044f73cc41.jpeg"},{"id":93018697,"identity":"48f85ae8-5504-4bda-82cf-5bc642440639","added_by":"auto","created_at":"2025-10-08 08:24:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46659,"visible":true,"origin":"","legend":"\u003cp\u003eThe assistant was positioned at the head side, the main surgeon at the foot side, and the instrument table and scrub nurse at the head side.\u003c/p\u003e","description":"","filename":"image2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/25bc8f2762e8f5d8c7c16dba.jpeg"},{"id":93019110,"identity":"da3393c2-6152-4ed5-97d7-d2d5be1d5be2","added_by":"auto","created_at":"2025-10-08 08:32:12","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":295536,"visible":true,"origin":"","legend":"\u003cp\u003eMarkers on the body surface before operation. The patient is placed in a supine position with a shoulder roll, with the head slightly extended and turned towards the contralateral side when perform the ipsilateral thyroidectomy.\u003c/p\u003e","description":"","filename":"image3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/926269d35a07c3a57cd533dd.jpeg"},{"id":93018693,"identity":"9c20b274-d6c1-449f-80ba-e01a6ff0363b","added_by":"auto","created_at":"2025-10-08 08:24:11","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":85815,"visible":true,"origin":"","legend":"\u003cp\u003eThe operating space for gasless trans-subclavian approach endoscopic thyroidectomy is Established by special suspension system: special suspension system: ① a selfdeveloped retractor with a suction device, ② a sterile bandage, ③ an anaesthesia stand.\u003c/p\u003e","description":"","filename":"image4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/3ec330c1c36d23bf940c9371.jpeg"},{"id":93018698,"identity":"8c81be05-118f-49a1-ab6f-0df1d3d954d7","added_by":"auto","created_at":"2025-10-08 08:24:12","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":123515,"visible":true,"origin":"","legend":"\u003cp\u003eThe image after completion of the ipsilateral thyroidectomy+central neck dissection. CCA common carotid artery; UPG upper parathyroid gland; TA trachea; ES esophagus; RLN recurrent laryngeal nerve.\u003c/p\u003e","description":"","filename":"image5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/93f12b7620341b3c1464430e.jpeg"},{"id":93018703,"identity":"cb2fc4d3-a084-4811-b367-fe7eba1ccbf7","added_by":"auto","created_at":"2025-10-08 08:24:13","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":305324,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient's head was turned towards the operating side to perform the contralateral thyroidectomy.\u003c/p\u003e","description":"","filename":"image6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/a95a940f68d99ae25b78fa30.jpeg"},{"id":93018692,"identity":"46b1de16-56ea-40af-8942-82bb8c3d688e","added_by":"auto","created_at":"2025-10-08 08:24:11","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":124190,"visible":true,"origin":"","legend":"\u003cp\u003eAn endoscopic suction device was used to push down the trachea, the contralateral thyroid lobe was lifted with the strap muscle by the retractor. TA trachea; RLN recurrent laryngeal nerve.\u003c/p\u003e","description":"","filename":"image7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/161effad5cbbce6be7c6d949.jpeg"},{"id":93018694,"identity":"61b2e87c-1465-4fbb-9da0-607c67b440f4","added_by":"auto","created_at":"2025-10-08 08:24:11","extension":"jpeg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":115355,"visible":true,"origin":"","legend":"\u003cp\u003eThe image after completion of contralateral thyroidectomy+central neck dissection with gasless trans subclavian approach. IJV internal jugular vein; UPG upper parathyroid gland; TA trachea; RLN recurrent laryngeal nerve; VN,vagus nerve.\u003c/p\u003e","description":"","filename":"image8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/835e5548cf730ffb17a1e1b4.jpeg"},{"id":93018700,"identity":"f6384094-df6d-427a-af2a-37692ebf3fe1","added_by":"auto","created_at":"2025-10-08 08:24:12","extension":"jpeg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":63705,"visible":true,"origin":"","legend":"\u003cp\u003eThe incision completely covered by the collar, healed well 6 month after the operation.\u003c/p\u003e","description":"","filename":"image9.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/3229f5d98f2891d680f5b5fd.jpeg"},{"id":93019111,"identity":"4a89ae09-21f2-413f-8579-cc5bb1ae150f","added_by":"auto","created_at":"2025-10-08 08:32:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1623202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6372469/v1/13d0df07-4a92-46e0-b6e0-a7e34638210d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eModified Gasless Endoscopic Total Thyroidectomy via a Unilateral Subclavian Approach for Papillary Thyroid Carcinoma\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eShimizu et al. first reported the\u0026nbsp;use of the subclavian approach for endoscopic thyroid surgery in 1998\u003csup\u003e\u0026nbsp;[1]\u003c/sup\u003e.Based on extensive clinical experience and surgical expertise, our team has systematically refined conventional subclavian endoscopic thyroidectomy through strategic modifications, including optimized incision placement, a modified surgical approach, and innovative instruments\u003csup\u003e[2]\u003c/sup\u003e.These innovations have resulted in a modified approach characterized by cosmetically advantageous incision placement, superior preservation of anterior cervical function\u003csup\u003e[3]\u003c/sup\u003e, reduced technical complexity, and improved thoroughness of central lymph node dissection.\u003c/p\u003e\n\u003cp\u003eAlthough this surgical technique has proven particularly effective for unilateral thyroid malignancies, the application of bilateral total thyroidectomy through a unilateral incision remains challenging, primarily because the trachea creates a substantial anatomical barrier, limiting surgical access to the contralateral thyroid gland and lymph nodes. Since March 2022, our team has successfully implemented a novel unilateral subclavian approach for bilateral thyroid procedures, achieving promising preliminary outcomes. This study systematically evaluated the technical innovations and clinical feasibility of this refined surgical approach.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA retrospective analysis was conducted on patients treated with modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach for papillary thyroid carcinoma at Sir Run Run Shaw Hospital affiliated with Zhejiang University School of Medicine from March 2022 to June 2024. The cohort included 6 males and 111 females, with a mean age of 39.7 \u0026plusmn; 11.0 years (range: 21\u0026ndash;66 years). Data on primary tumour size, surgery duration, postoperative complications, hospitalization\u0026nbsp;time, number of central lymph nodes dissected, and follow-up measurements, including thyroglobulin level and ultrasonography of the thyroid area and neck, were recorded. All surgeries were performed in accordance with the Guidelines for the diagnosis and treatment of thyroid nodules and differentiated thyroid cancer (the second edition) by the same team. The collection of clinical data was approved by the Ethics Committee of Sir Run Run Shaw Hospital after informed consent was written by each patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Instruments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical instruments used in this study included standard endoscopic thyroid surgery instruments and custom-developed tools. (1) Standard instruments consisted of a 30\u0026deg;, 10-mm diameter high-definition endoscope with a camera unit, endoscopic grasping forceps, endoscopic separating forceps, an endoscopy suction device(KARL STORZ, Germany), and a 36-cm ultrasonic scalpel(Johnson \u0026amp; Johnson, USA). (2) Custom-developed instruments comprised two suspension hooks with suction tubes, each of different lengths 10 cm and 12 cm)(Fig. 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: (1) papillary thyroid carcinoma confirmed by preoperative ultrasound-guided fine-needle aspiration biopsy, with a maximum tumour diameter \u0026le;3 cm and the absence of lateral cervical lymph node metastasis; (2) surgical procedure including bilateral thyroid lobectomy plus unilateral or bilateral central neck dissection; and (3) no previous history of neck surgery or radiation therapy.\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were as follows: (1) preoperative evidence of primary tumour or lymph node invasion into adjacent structures (trachea, oesophagus, larynx, or recurrent laryngeal nerve);(2) a tumour in the contralateral gland located close to the entry point of the larynx of the recurrent laryngeal nerve(RLN); and (3) a history of keloid formation or a known predisposition to keloid scarring.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient\u0026nbsp;was placed in a supine position with a shoulder roll, with the head slightly extended and turned towards the contralateral side.General anaesthesia was administered via oral intubation using a nerve-monitoring endotracheal tube（Medtronic, USA）. The anaesthesia stand was fixed between the contralateral axillary apex and shoulder midpoint to facilitate cavity suspension. After the operative area was sterilized and draped, the assistant was positioned at the head side, the main surgeon at the foot side, and the instrument table and scrub nurse at the head side(Fig. 2). An incision, approximately 3\u0026ndash;4 cm in length, was marked along the subclavian skin line, just below the clavicle, between the anterior border of the sternocleidomastoid muscle(SCM) and the posterior border of the sternum(Fig 3).\u003c/p\u003e\n\u003cp\u003eDissection of the anterior neck region was carried out by layer under the platysma using electric cautery under direct vision. After the clavicular and sternal branches of the SCM were exposed, the space between these two branches was separated, and a modified retractor was placed to lift the clavicular branches(Fig 4). The strap muscles were exposed and dissected laterally by a Harmonic scalpel (Johnson \u0026amp; Johnson, Cincinnati, Ohio, USA) under endoscopic guidance. The thyroid cavity was then created by lifting the strap muscles with the retractor, allowing for dissection of the thyroid gland. The thyroid gland and the strap muscles were lifted together using the retractor. The RLN was exposed at the level of the inferior thyroid pole and dissected upwards to its entry point into the larynx, with continuous intraoperative nerve monitoring\u003csup\u003e[4]\u003c/sup\u003e. Central compartment lymph node dissection was performed along with thyroidectomy. When the superior pole region of the thyroid gland was approached, care was taken to preserve the parathyroid gland in situ as much as possible. The upper pole of the thyroid gland was drawn downwards, and the superior thyroid vessels were identified via nerve monitoring and then divided close to the thyroid gland using a Harmonic scalpel to protect the external branch of the superior laryngeal nerve (EBSLN).The thyroid gland was then retracted medially, and careful dissection was performed to divide the Berry ligament to complete the ipsilateral thyroidectomy(Fig 5). After specimen removal, the patient\u0026apos;s head was turned, and the surgical bed was adjusted towards the operating side to facilitate elevation of the contralateral thyroid gland（Fig 6）. An endoscopic suction device was used to push down the trachea, allowing further separation of the thyroid from the tracheal tissue up to the contralateral edge(Fig 7). The retractor was then moved to the inferior pole region of the cavity, and dissection was performed laterally along the trachea to identify the contralateral RLN under continuous nerve monitoring. After the nerve was isolated, the inferior pole of the thyroid was elevated to expose the RLN up to the point of entry into the larynx. The dissection continued downwards to the level of the brachiocephalic trunk and extended laterally to expose the contralateral carotid sheath, which served as the lateral boundary for central neck dissection. The inferior parathyroid glands were preserved in situ whenever possible. In cases where preservation was not feasible or the vascular supply was compromised, immediate parathyroid gland autotransplantation was performed\u003csup\u003e[5]\u003c/sup\u003e. Following completion of the inferior pole dissection, the retractor was moved to expose the superior pole region of the thyroid. Dissection was performed along the cricothyroid space towards the superior pole, while the EBSLN was identified and protected under continuous nerve monitoring. The superior pole vessels were then gradually severed. The superior pole was pulled medially and downwards, while dissection proceeded along the lateral border of the thyroid gland down to the cricothyroid muscle level. After both superior and inferior pole dissections were completed, the thyroid gland was pulled laterally.\u0026nbsp;Endoscopic\u0026nbsp;suction was used to push down the trachea, creating additional working space for meticulous dissection of the gland. The Berry\u0026rsquo;s ligament was carefully dissected and divided in a stepwise fashion. The RLN and superior parathyroid gland were meticulously dissected from the thyroid gland. Finally, the contralateral\u0026nbsp;thyroid gland\u0026nbsp;and contralateral central compartment\u0026nbsp;specimens\u0026nbsp;were removed as\u0026nbsp;en blocs\u0026nbsp;(Fig.\u0026nbsp;8).The resected specimens were carefully examined for any parathyroid glands, with immediate autotransplantation performed if identified.\u003c/p\u003e\n\u003cp\u003eSerum parathyroid hormone (PTH) and calcium levels were measured on postoperative day one to assess parathyroid function. Hypoparathyroidism was defined as a decrease in PTH to the lower limit of\u0026nbsp;the normal range, necessitating calcium supplementation for symptom control. If hoarseness occurred postoperatively, laryngoscopy was performed to assess vocal cord mobility. Hypoparathyroidism and RLN palsy were classified as permanent complications if they remained unresolved within 6 months.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll 117 patients underwent successful endoscopic surgery without conversion to open surgery. 17 patients underwent total thyroidectomy with unilateral central compartment dissection, and 100 patients underwent total thyroidectomy with bilateral central compartment dissection (Table 1).The mean operation time was 154.2\u0026plusmn;32.4 minutes (range: 85\u0026ndash;240 minutes), with a mean intraoperative blood loss of19.0\u0026plusmn;11.2 mL (range: 5\u0026ndash;100 mL). Specifically, the mean intraoperative blood loss volume was 17.7\u0026plusmn;7.52 mL (range: 10\u0026ndash;30 mL)for total thyroidectomy with unilateral central compartment dissection and 19.2\u0026plusmn;11.7 mL (range: 5\u0026ndash;100 mL)for bilateral central compartment dissection. The mean postoperative drainage volume was 137.3\u0026plusmn;58.8 mL (range: 30\u0026ndash;420 mL), with 128.53\u0026plusmn;36.6 mL (range: 80\u0026ndash;212 mL) for unilateral central compartment dissection and 138.8\u0026plusmn;61.8 mL (range: 30\u0026ndash;420 mL)for bilateral dissection. The mean postoperative hospital stay was 3.2\u0026plusmn;1.1 days (range: 2\u0026ndash;7 days). The mean maximum diameter of papillary thyroid carcinoma was 8.4\u0026plusmn;4.7 mm (range: 3\u0026ndash;25 mm), with a mean of 12.4\u0026plusmn;6.4 harvested central compartment lymph nodes (range: 0\u0026ndash;30) and 1.5\u0026plusmn;2.1 metastatic lymph nodes (range: 0\u0026ndash;10). Postoperative pathological staging included 87 cases of pT1a, 23 cases of pT1b, 5 cases of pT2, and 2 cases of pT3b. There were 51 cases of pN0 and 66 cases of pN1a(Table2).Postoperative transient hypoparathyroidism occurred in 6patients, which resolved by the one-month follow-up. Transient recurrent laryngeal nerve injury occurred in 3patients, all of whom were resolved by the three-month follow-up. There were 2 cases of postoperative bleeding managed by haematoma evacuation through the original subclavian incision, with satisfactory recovery. There were no instances of permanent RLN, permanent hypoparathyroidism, or infections. One month post surgery, all the incisions had healed well, with satisfactory cosmetic results. Patients were followed for 3\u0026ndash;15 months postoperatively, with a mean thyroglobulin level of 0.31\u0026plusmn;0.58ng/mL (range: 0\u0026ndash;3.56 ng/mL). Ultrasound examination of the thyroid and cervical lymph nodes six months post surgery revealed no local recurrence or metastasis. One patient experienced lateral neck lymph node recurrence 13 months after surgery and underwent a second bilateral neck lymph node dissection.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOver the past decade, various techniques\u0026nbsp;for endoscopic thyroid surgery have been introduced\u003csup\u003e[6-12]\u003c/sup\u003e. Shimizu et al. \u003csup\u003e[1]\u003c/sup\u003e first reported endoscopic thyroid surgery via the subclavian approach in 1998, which allows for unilateral thyroidectomy, near-total thyroidectomy, and total thyroidectomy. During the procedure, a 3\u0026ndash;4 cm incision is made in the chest wall skin beneath the clavicle, which can be covered by clothing. For bilateral thyroid surgery, extensive dissection of the anterior neck and chest wall via the midline cervical approach is needed. Our team improved the traditional subclavian endoscopic thyroid surgery by optimizing incision placement, surgical pathways, and instruments\u003csup\u003e[2]\u003c/sup\u003e. Compared with other techniques, the trans-subclavian approach features a shorter surgical path, requiring less flap separation during the establishment of the surgical space, which significantly reduces trauma to patients and relieves skin numbness. This approach also provides a concealed incision, better preservation of anterior neck function, lower operational difficulty, and thorough central compartment dissection, making it particularly suitable for unilateral thyroid cancer surgery.\u003c/p\u003e\n\u003cp\u003eThe subclavian approach is similar to axillary endoscopic thyroid surgery, both of which utilize a lateral approach. Owing to obstruction by the trachea, conventional endoscopic instruments cannot access the entire thyroid, and exposure of the contralateral thyroid, particularly at the entry point of the RLN into the larynx, is challenging. Additionally, the limited operating space results in significant leverage effects during instrument manipulation, causing traction on the gland. To protect the RLN, there is a tendency to leave residual thyroid tissue at the point of laryngeal entry, making contralateral thyroid surgery more difficult. This approach has been attempted by a few centres both domestically and internationally. While steerable robotic arms make total thyroidectomy feasible,\u0026nbsp;sufficient working space must be created for comfortable movements of\u0026nbsp;the robotic arms\u003csup\u003e[13]\u003c/sup\u003e.\u0026nbsp;Moreover, robotic surgery can be expensive and is not universally available.\u003c/p\u003e\n\u003cp\u003eIn this study, our team improved the surgical procedure by analysing the anatomical structure of the contralateral thyroid and lymph nodes and considering the advantages of the subclavian approach, which involves shorter tunnels and fewer operational constraints. First, to fully expose the contralateral gland, the patient\u0026apos;s head is turned to the ipsilateral side, and the operating table is tilted towards the same side, making the contralateral thyroid gland more superficial and easier to manipulate. Second, to create more visual space, we removed the ipsilateral thyroid gland before resecting the contralateral thyroid lobe. During contralateral surgery, the operating space is limited; however, by appropriately adjusting the retractor, the space can be shifted towards the target operation site, such as by moving the retractor cranially for superior pole dissection or caudally for increased space at the inferior pole. The space between the contralateral thyroid and the strap muscle is not separated prematurely; instead, the entire contralateral thyroid lobe is lifted with the strap muscle by the retractor. If necessary, the retractor can be positioned beneath the contralateral thyroid lobe for elevation, facilitating posterior dissection. An endoscopic suction device can also be inserted into the surgical field, using the skin incision as a fulcrum to depress the trachea medially, thereby creating symmetrical traction and providing adequate space for separation.\u0026nbsp;Owing\u0026nbsp;to the limited symmetrical traction in\u0026nbsp;the\u0026nbsp;endoscopic thyroid, preservation of the inferior parathyroid gland in situ becomes challenging.\u0026nbsp;The parathyroid\u0026nbsp;glands located within the thymus and those with\u0026nbsp;an\u0026nbsp;intact blood supply should be preserved in situ as much as possible. Any parathyroid glands that are inadvertently excised with the thyroid specimen or compromised by vascular supply should be identified in resected specimens and considered for immediate autotransplantation.\u003c/p\u003e\n\u003cp\u003eIn the process of RLN dissection, the nerve is first identified at the inferior pole of the thyroid and dissected superiorly to its entry point into the larynx. The superior\u0026nbsp;pole is then dissected through the space between the cricothyroid ligament, with downwards traction of the gland to increase mobility. After the inferior and superior poles of the thyroid are separated, the surrounding tissue at the point where the RLN enters the larynx is dissected close to the gland. The RLN and superior parathyroid gland are then released to complete the removal of the contralateral thyroid gland. This method results in no significant residual tissue in the laryngeal entry area, requires less time for nerve separation and protection, and simplifies the operative procedure.\u003c/p\u003e\n\u003cp\u003eThe point where the RLN enters the larynx is the most challenging area for surgical operation, necessitating preoperative assessment. When a tumour is located in this area, careful consideration should be given to either accessing from that side or selecting an alternative surgical approach. Given the relative difficulty in handling the contralateral thyroid, the incision can be appropriately extended in the early stages of implementing this approach to facilitate subsequent operations. In this study, 35 cases were treated via a left-sided approach, and 82 cases were treated via a right-sided approach, with comparable operative times for the contralateral approach. However, during left-sided approaches, interference between the primary surgeon and the endoscope-holding assistant was more frequent, likely because all surgeons in this study were right-handed and because the assistant holding the endoscope was positioned on the right side of the primary surgeon. Therefore, when bilateral thyroid tumours are comparable in size and characteristics, a right-sided approach may be preferable to reduce operational difficulty.\u003c/p\u003e\n\u003cp\u003eCompared with open neck surgery,\u0026nbsp;incisions for subclavian endoscopic thyroid surgery can be concealed with clothing, offering better aesthetic results and greater patient acceptance(Fig 9). Compared withother endoscopic approaches for total thyroidectomy, this approach minimizes subcutaneous tunnelling, thereby significantly reducing operative complexity. In this study, the mean intraoperative blood loss was only 19.0\u0026plusmn;11.2 mL, the postoperative drainage volume was 137.3\u0026plusmn;58.8 mL, and the mean length of postoperative hospital stay was 3.2\u0026plusmn;1.1 days, demonstrating both safe intraoperative procedures and rapid postoperative recovery. Histopathological examination revealed that an average of 12.4\u0026plusmn;6.6 central compartment lymph nodes were dissected, with 1.5\u0026plusmn;2.1 metastatic lymph nodes, demonstrating thorough tumour and lymph node clearance.\u003c/p\u003e\n\u003cp\u003eThis approach retains the advantages of\u0026nbsp;a gasless endoscopic approach, eliminating insufflation-related CO\u003csub\u003e2\u003c/sub\u003e complications. During cavity creation, anterior neck flap dissection is minimal, the cavity is formed quickly, and the subcutaneous tunnel is short, reducing operational constraints and difficulty, with a high rate of complete exposure in the central compartment [17]. Additionally, this approach enables bilateral thyroidectomy via the intermuscular plane of the SCM, resulting in enhanced postoperative sensory and swallowing functions while preserving anterior neck functionality. This approach utilizes the subclavian retractor device developed by our team, which requires simple equipment and has low surgical costs. Compared with the transoral vestibular approach for bilateral thyroidectomy, the limitation of the unilateral subclavian approach is that subclavian scars remain postoperatively, making it unsuitable for patients with keloid-prone skin. However, this approach avoids the potential infection risks associated with the transoral vestibular approach. Given proper indications, gasless endoscopic total thyroidectomy via the unilateral subclavian approach is safe and feasible, achieving thorough tumour resection with optimal incision concealment and demonstrating significant clinical value. However, given the limited sample size of this study, further large-scale, multicentre clinical trials are warranted to validate the efficacy and applicability of this surgical approach in thyroid cancer treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKazuo Shimizu 1, Wataru Kitagawa, Haruki Akasu, et al. Video-assisted minimally invasive endoscopic thyroid surgery using a gasless neck skin lifting method--153 cases of benign thyroid tumors and applicability for large tumors[J].Biomed Pharmacother . 2002;56 Suppl 1:88s-91s. https://doi: 10.1016/s0753-3322(02)00239-1\u003c/li\u003e\n\u003cli\u003eJinxi, J, Gaofei He, et al. Single-incision gasless trans-subclavian endoscopic approach thyroidectomy. Updates Surg (2024). https://doi: 10.1007/s13304-024-01948-7\u003c/li\u003e\n\u003cli\u003eJandee,L, In, et al. Comparative analysis of oncological outcomes and quality of life after robotic versus conventional open thyroidectomy with modified radical neck dissection in patients with papillary thyroid carcinoma and lateral neck node metastases.[J].Journal of Clinical Endocrinology \u0026amp; Metabolism, 2013. https://doi:10.1210/jc.2013-1583.\u003c/li\u003e\n\u003cli\u003eDralle H, Sekulla C, et al. German IONM Study Group. Intraoperative monitoring of the recurrent laryngeal nerve in thyroid surgery. World J Surg. 2008 Jul;32(7):1358-66. https://doi: 10.1007/s00268-008-9483-2\u003c/li\u003e\n\u003cli\u003eZhang D, Gao L, et al. Predictors of graft function after parathyroid autotransplantation during thyroid surgery[J]. Head Neck, 2018, 40(11):2476-2481. https://doi: 10.1002/hed.25371\u003c/li\u003e\n\u003cli\u003eHuscher CS , Chiodini S , et al. Endoscopic right thyroid lobectomy . Surg Endosc 11:877. https://doi: 10.1007/s004649900476\u003c/li\u003e\n\u003cli\u003eIkeda Y , Takami H , Sasaki Y ,et al.Endoscopic resection of thyroid tumors by the axillary approach[J].Journal of Cardiovascular Surgery, 2000, 41(5):791-2. https://doi :10.1177/106689690000800421.\u003c/li\u003e\n\u003cli\u003eOhgami M , Ishii S , Arisawa Y ,et al.Scarless endoscopic thyroidectomy: breast approach for better cosmesis.[J].Surgical Laparoscopy Endoscopy \u0026amp; Percutaneous Techniques, 2000, 10. https://doi:10.1097/00129689-200002000-00001.\u003c/li\u003e\n\u003cli\u003eIkeda Y, Takami H, et al. Total endoscopic thyroidectomy: axillary or anterior chest approach. Biomed Pharmacother. 2002;56 Suppl 1:72s-78s. https://doi: 10.1016/s0753-3322(02)00274-3.\u003c/li\u003e\n\u003cli\u003eL ee KE, Kim HY, et al. Postauricular and axillary approach endoscopic neck surgery: a new technique. World J Surg. 2009 Apr;33(4):767-72. https://doi: 10.1007/s00268-009-9922-8. \u003c/li\u003e\n\u003cli\u003eAnuwong A. Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases. World J Surg. 2016 Mar;40(3):491-7. https://doi: 10.1007/s00268-015-3320-1. \u003c/li\u003e\n\u003cli\u003eJinxi J , Gaofei He, et al. Novel suspension system for gasless transoral vestibular thyroidectomy. Surg Endosc. 2023 Feb;37(2):1070-1076. https://doi: 10.1007/s00464-022-09528-9. \u003c/li\u003e\n\u003cli\u003eKim M J , Nam K H , Lee S G ,et al.Yonsei Experience of 5000 Gasless Transaxillary Robotic Thyroidectomies[J].World Journal of Surgery, 2018. https://doi:10.1007/s00268-017-4209-y.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable1 Demographic and clinical data of study population (n=117)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"319\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 41.2935%;\"\u003e\n \u003cp\u003eRange/percent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003e39.7\u0026plusmn;11.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\n \u003cp\u003e21~66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\n \u003cp\u003e94.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eExtent of surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eTTUCND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\n \u003cp\u003e14.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47.0365%;\"\u003e\n \u003cp\u003eTTBCND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.6562%;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 25.4149%;\"\u003e\n \u003cp\u003e85.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTTUCND，total thyroidectomy with unilateral CND；\u003c/p\u003e\n\u003cp\u003eTTBCND, total thyroidectomy with bilateral CND\u003c/p\u003e\n\u003cp\u003eTable 2 Surgical outcomes of gasless endoscopic thyroidectomy via modifed trans-subclavian approach (n=117)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"410\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 14.5819%;\"\u003e\n \u003cp\u003eRange/percent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003ePathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eTumor size（mm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e8.3\u0026plusmn;4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e3~25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eT stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003epT1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e74.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003epT1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e19.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003epT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e1.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eN stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003ePn0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e43.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003ePn1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e56.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eOperative time(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e154.2\u0026plusmn;32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e85-240min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eNo. of dissected LNs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e12.4\u0026plusmn;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e0~35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eNo. of LNs metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e1.5\u0026plusmn;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\n \u003cp\u003e0~10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003ePostoperative hospital stay（d）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e3.2\u0026plusmn;1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.3194%;\"\u003e\n \u003cp\u003e2-7d\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eTransintvocal cord palsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eTransinthypoparathyoidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 46.825%;\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.158%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 29.7746%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endoscopy, Papillary thyroid carcinoma, Subclavian approach, Total thyroidectomy","lastPublishedDoi":"10.21203/rs.3.rs-6372469/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6372469/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"To evaluate the technical feasibility and surgical outcomes of modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach for treating papillary thyroid carcinoma. A retrospective analysis of the clinical data of 117 patients with papillary thyroid carcinoma who underwent modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach at the Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, from March 2022 to June 2024 was conducted. All surgeries were successfully completed endoscopically without conversion to open surgery. The mean tumour size was 8.4±4.7 mm, and the mean operative time was 154.2±32.4 minutes. The mean number of harvested central compartment lymph nodes was 12.4±6.6, and the mean length of postoperative hospital stay was 3.2±1.1 days. Postoperative complications included temporary hypoparathyroidism (n=6, 5.1%), temporary hoarseness (n=3, 2.6%), and postoperative haemorrhage (n=2, 1.7%). All temporary complications resolved spontaneously within three months. No permanent recurrent laryngeal nerve（RLN）palsy, permanent hypoparathyroidism, or incision infection occurred. During the follow-up period, one patient developed lateral neck lymph node recurrence at 13 months postoperatively and subsequently underwent bilateral neck dissection. Modified gasless endoscopic total thyroidectomy via a unilateral subclavian approach demonstrated feasibility in carefully selected patients. This technique enables comprehensive central compartment lymph node dissection while preserving anterior cervical function, suggesting its potential clinical applicability.","manuscriptTitle":"Modified Gasless Endoscopic Total Thyroidectomy via a Unilateral Subclavian Approach for Papillary Thyroid Carcinoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 08:23:47","doi":"10.21203/rs.3.rs-6372469/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-24T02:03:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T10:35:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T08:13:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117186133039119088648655035378235087241","date":"2025-09-29T00:37:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208090292009918252545755826744632524529","date":"2025-09-25T08:02:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T07:58:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-11T11:59:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-11T11:39:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-10T04:05:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-04T00:31:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf428911-66a4-4562-8d38-aeeaf944e104","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":55912493,"name":"Biological sciences/Cancer/Endocrine cancer/Thyroid cancer"},{"id":55912494,"name":"Health sciences/Endocrinology/Endocrine system and metabolic diseases/Thyroid diseases"}],"tags":[],"updatedAt":"2026-04-22T14:23:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 08:23:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6372469","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6372469","identity":"rs-6372469","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}