Anatomical landmark-guided working space creation in endoscopic thyroidectomy via the bilateral areolar approach

Totally endoscopic thyroidectomy via the bilateral areolar approach (ETAA) is gaining popularity due to its cosmetic advantages. However, establishing a stable working cavity remains technically challenging and lacks standardization. This study evaluated the feasibility and safety of a standardized anatomical landmark-guided technique for working-space creation in selected patients with papillary thyroid carcinoma (PTC). We conducted a retrospective, single-center observational study of consecutive female patients with PTC who underwent ETAA at the First People’s Hospital of Zunyi between May 2024 and April 2025. The technique combined preoperative surface marking of anatomical landmarks with stepwise tumescent-fluid and air injection. The primary outcomes were cavity establishment time, the success rate of working-space creation, and total operative time. Secondary outcomes included intraoperative blood loss, postoperative drainage volume, Visual Analog Scale (VAS) pain score at 48 h, duration of drainage, postoperative hospital stay, cosmetic satisfaction, central lymph node yield, and postoperative complications. A total of 194 female patients were included, comprising 113 patients who underwent lobectomy and 81 who underwent total thyroidectomy. The mean cavity establishment time was 13.80 ± 2.78 min and did not differ significantly between the lobectomy and total thyroidectomy groups (13.5 ± 2.40 vs. 13.2 ± 2.20 min, respectively; P = 0.312). The working-space creation success rate was 98.97%, and the mean total operative time was 103 ± 26 min. Mean intraoperative blood loss was 17.58 ± 6.60 mL, and the mean postoperative hospital stay was 2.94 ± 0.79 days. The mean VAS pain score was 2.81 ± 1.08. A cosmetic satisfaction score of 5 was reported by 188 patients (96.9%). Postoperative complications occurred in 27 patients (13.9%), including transient recurrent laryngeal nerve palsy in 6 patients (3.1%) and transient hypoparathyroidism in 14 patients (7.1%). No permanent recurrent laryngeal nerve palsy, permanent hypoparathyroidism, surgical-site infection, or skin-flap injury was observed. In selected female patients with PTC, the anatomical landmark-guided technique enabled efficient and successful working-space creation during ETAA and was associated with favorable short-term perioperative outcomes. Prospective multicenter studies involving multiple surgeons and comparative groups are needed to validate its reproducibility and comparative effectiveness.