Port-guided port placement: An innovative technique in endoscopic thyroidectomy

Abstract Endoscopic thyroidectomy using the bilateral axillo-breast approach (BABA) provides excellent cosmetic outcomes and surgical completeness. Conventional techniques often require hydro-dissection and, in some modifications, specialized tunnelling instruments for flap creation. Hydro-dissection may impair visualization due to camera fogging and tissue charring, while custom instruments increase procedural cost and limit accessibility in resource-constrained settings. We describe a novel port-guided port placement technique for BABA endoscopic thyroidectomy that eliminates the need for hydro-dissection and specialized tunnelling devices, named by us as P3 modification (P- Port P- guided Port P – Placement) Following standard patient positioning and surface marking, a 10-mm port is introduced through an anterior axillary incision after limited blind subcutaneous dissection with a haemostatic artery forceps. This initial port serves as a guide for the sequential placement of additional working ports in the appropriate plane. Subsequent flap elevation and thyroid dissection are performed under direct endoscopic visualization. The technique is applicable to both hemi- and total thyroidectomy while preserving key structures, including the recurrent laryngeal nerves and parathyroid glands. The proposed modification minimizes blind dissection, avoids complications associated with excessive hydro-dissection, and obviates the need for custom-made instruments. Improved visualization, reduced risk of inadvertent deep or superficial dissection, decreased bleeding, and potentially shorter operative time are additional benefits. The technique also reduces procedural costs and enhances the feasibility of remote-access thyroidectomy in low-resource settings. Port-guided port placement is a simple, safe, and cost-effective modification of BABA endoscopic thyroidectomy that improves accessibility while maintaining the principles of minimally invasive thyroid surgery.