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Method Article

A Novel Contralateral Axillo-Bilateral-Breast Approach for Endoscopic Thyroid Surgery

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DOI:

10.3791/70996

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July 28th, 2026

 ,  ,  ,  , 
1Department of Thyroid, Parathyroid, Breast and Hernia Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, 2Department of Hepatobiliary and Pancreatic Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital

* These authors contributed equally

In This Article

Summary

This protocol presents a novel contralateral axillo-bilateral-breast approach for endoscopic thyroidectomy that optimizes surgical positioning and operative space while achieving excellent cosmetic outcomes.

Abstract

The incidence of thyroid cancer has increased significantly, with surgical resection remaining the primary treatment modality. Traditional open thyroidectomy leaves visible neck scars that cause significant cosmetic concerns for patients. This protocol describes a novel endoscopic thyroidectomy technique using a contralateral axillo-bilateral-breast approach (CABBA-ET). The key innovations include: (i) supine patient positioning without leg separation, reducing surgeon discomfort and patient hip strain risk; (ii) optimized camera and instrument positioning that minimizes surgical field obstruction; and (iii) trans-areolar incisions providing excellent scar concealment. In a cohort of 130 patients treated between 2019 and 2025, this approach demonstrated operative safety comparable to that of conventional thyroidectomy, with superior cosmetic outcomes. The technique is suitable for papillary thyroid carcinomas ≤2 cm in maximum diameter without extensive lymph node metastasis, and benign nodules <6 cm. All patients achieved satisfactory cosmetic results with no permanent complications. This approach represents a safe and feasible alternative for patients seeking cosmetically favorable thyroid surgery.

Introduction

Over the past two decades, thyroid cancer incidence has risen dramatically, becoming the third most common malignancy among women1. Surgical resection remains the cornerstone of thyroid disease management2. Traditional open thyroidectomy via the Kocher incision leaves permanent neck scars that cause significant psychological distress, particularly for patients who prefer low-collared clothing3,4. Postoperative complications such as hypertrophic scarring further impact quality of life5.

To address these concerns, various extra-cervical endoscopic approaches have been developed, including transoral6, submental7, trans-axillary8, chest-breast, and bilateral axillo-breast approach (BABA) techniques9. However, each approach has inherent limitations. The transoral approach raises concerns regarding mental nerve injury and infection risk6. The chest-breast approach (CBA) and unilateral axillo-breast approach (UABA) may encounter interference from the ipsilateral clavicle and sternocleidomastoid muscle. Additionally, the BABA approach requires patients to be positioned in a split-leg position, which can cause hip strain and requires surgeons to stand between the patient's legs, leading to lumbar discomfort during prolonged procedures.

To optimize these limitations, we developed a modified approach termed the contralateral-axillo-bilateral-breast approach for endoscopic thyroidectomy (CABBA-ET). This technique offers three key advantages: First, the patient remains in a standard supine position without leg separation, eliminating hip strain risk and allowing surgeons to maintain ergonomic positioning throughout the procedure. Second, the camera port is placed at the ipsilateral areola while the surgeon operates from the contralateral side, preventing instrument-camera interference and optimizing surgical field visualization. Third, all incisions are made through the areolae, ensuring excellent cosmetic concealment even if incision extension is required for specimen retrieval.

This protocol presents a detailed, step-by-step description of the CABBA-ET technique, enabling accurate replication by both experienced endoscopic surgeons and those new to extra-cervical thyroidectomy. We demonstrate the safety and feasibility of this approach through representative results from 130 consecutive cases performed at our institution.

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Protocol

1. Patient selection and preoperative assessment

  1. Inclusion criteria
    1. Evaluate patients for CABBA-ET candidacy based on the following criteria: (i) the patient meets standard indications for thyroid surgery (e.g., confirmed or suspicious malignancy, symptomatic benign goiter, progressive nodule enlargement, or refractory hyperthyroidism); and (ii) the patient expresses cosmetic concerns or anxiety regarding visible neck scarring.
    2. For benign thyroid nodules, verify that the maximum diameter is < 6 cm by ultrasound measurement.
    3. For hyperthyroidism requiring surgical treatment, confirm goiter Grade II or below according to the 1994 WHO classification (Stage 0: no goiter visible or palpable with neck fully extended; Stage 1A: palpable only, not visible even with neck fully extended; Stage 1B: palpable and visible only when neck is fully extended; Stage 2: goiter visible with neck in normal position; Stage 3: very large goiter visible even at a considerable distance), verified by physical examination (inspection with neck in neutral position, palpation to assess texture and nodules) and cervical ultrasound to measure thyroid volume and nodule size.
    4. For thyroid malignancies, confirm maximum tumor diameter < 2 cm by preoperative high-resolution neck ultrasound (measurement in three orthogonal planes, the largest dimension recorded).
      1. Verify absence of adjacent organ involvement by ultrasound evidence of intact thyroid capsule, preserved sliding sign between the tumor and trachea/esophagus, and no invasion into major vessels on color Doppler. In equivocal cases, contrast-enhanced CT or MRI is performed to exclude gross extrathyroidal extension.
        NOTE: With advancing experience and equipment capabilities, indications may be appropriately expanded, particularly in centers with extensive endoscopic expertise.
  2. Exclusion criteria
    1. Exclude patients with severe systemic diseases that contraindicate elective surgery, such as uncontrolled heart failure, recent myocardial infarction (< 6  months), severe COPD, decompensated cirrhosis, end‑stage renal disease, or uncorrectable coagulopathy.
    2. Exclude patients with deformities (e.g., severe pectus excavatum, clavicular malunion, limited neck extension) or active infections (e.g., cellulitis, abscess, herpes zoster) in the thoracic, clavicular, or potential surgical access pathways.
    3. Consider relative contraindications, including previous neck surgery or radiotherapy, presence of neck scars, obesity (body mass index > 30 kg/m2), or prior ablation treatment.
    4. Exclude patients with preoperative imaging showing lymph node metastasis in neck zones I or V, lymph node metastasis below the sternoclavicular joint level, infraclavicular or superior mediastinal lymph node involvement, or fused, fixed, or cystic metastatic lymph nodes at any site.
  3. Preoperative preparation
    1. Verify availability of all required equipment: laparoscopic imaging system with 10 mm 30-degree endoscope, CO2 insufflator, ultrasonic scalpel, endoscopic surgical instruments, electrocautery hook, endoscopic nerve monitoring forceps, nerve monitor, and laparoscopic recording equipment.
    2. Instruct the patient to consume a light diet for 24 h preoperatively, ensure adequate sleep, and cease smoking at least 2 weeks before surgery.
    3. Perform fine-needle aspiration (FNA) biopsy for suspicious nodules and confirm pathological diagnosis preoperatively.
    4. Perform preoperative laryngoscopy to document baseline vocal cord function in all patients, as this is mandatory for thyroid surgery, especially when intraoperative nerve monitoring is used.
    5. Measure baseline serum calcium, parathyroid hormone (PTH), and 25-hydroxyvitamin D levels preoperatively to aid in the interpretation of postoperative hypocalcemia.
    6. Obtain informed consent after thoroughly discussing the procedure, potential risks, benefits, and alternative treatment options with the patient.

2. Anesthesia management

  1. Administer general anesthesia with orotracheal intubation.
  2. To facilitate intraoperative recurrent laryngeal nerve monitoring, position a specialized electromyography (EMG) endotracheal tube (e.g., NIM™ or similar) with the electrodes in contact with the vocal cords, and confirm its correct placement by nerve stimulation and waveform acquisition before surgical draping.
  3. Titrate muscle relaxation carefully: give a single dose of short-acting neuromuscular blocking agent for intubation only, and do not administer additional muscle relaxants during the procedure to preserve reliable nerve monitoring signals.
  4. Adjust mechanical ventilation to maintain normocapnia while accommodating CO₂ insufflation pressures of 6–8 mmHg in the subcutaneous workspace. Monitor hemodynamic parameters continuously, with particular attention to potential hypercapnia or gas embolism related to prolonged CO₂ insufflation.

3. Trocar placement and working space creation (Figure 1 and Figure 2)

  1. Surgical positioning
    1. Place the patient in a supine position. The surgeon stands on the patient's left, and the assistant stands on the right. Place the endoscope monitor at the patient's head.
  2. Camera port placement (ipsilateral areola)
    1. Make a 1.2 cm (12 mm) incision along the areolar margin from the 12 o'clock to 3 o'clock position on the affected side.
    2. Dissect the subcutaneous tissue to the fat layer using electrocautery.
    3. Insert a 10 mm trocar close to the subcutaneous fat layer into the superficial fascia plane.
    4. Advance the trocar to approximately 3 cm below the suprasternal notch to establish the observation port.
    5. Insert the 10 mm, 30-degree endoscope through this port.
  3. First operating port placement (contralateral areola)
    1. Make a 0.8 cm (8 mm) incision at the 9–12 o'clock position of the contralateral areola.
    2. Insert a 5 mm trocar into the subcutaneous fat layer.
    3. Advance the trocar under direct endoscopic visualization until it converges with the camera port in the anterior neck space.
    4. Insert an electrocautery hook through this port to begin expanding the subcutaneous working space.
  4. Second operating port placement (contralateral axilla)
    1. After exposing the contralateral sternocleidomastoid muscle, identify the anterior axillary line on the contralateral side.
    2. Make a 0.8 cm (8 mm) incision along the natural skin creases at the contralateral anterior axillary line.
    3. Insert a 5 mm trocar as the second operating port.
      NOTE: The surgeon stands on the side opposite to the affected thyroid lobe, while the assistant holding the endoscope stands on the affected side.

4. Flap dissection and working space establishment

  1. Initial space creation
    1. Connect the CO₂ insufflation system and set the gas flow rate to 10 L/min with an initial pressure of 4 mmHg.
    2. Create a subcutaneous space closely beneath the skin using needle expansion.
    3. Expand the lateral space to place a second trocar. Continue the dissection beneath the superficial fascia down to the suprasternal fossa. Then, separate the flap along the plane just above the platysma muscle using the electrocautery hook.
    4. Continue dissecting superiorly along the subplatysmal plane to the level of the thyroid cartilage and laterally to the anterior border of the sternocleidomastoid muscle.
  2. Working space expansion
    1. Increase the CO₂ pressure to 6 mmHg.
    2. Expand the working space bilaterally to the posterior borders of the sternocleidomastoid muscles.
    3. Increase the insufflation pressure to 8 mmHg and maintain this pressure throughout the procedure.
  3. Midline access and thyroid exposure
    1. Identify the linea alba (midline raphe between the strap muscles) under endoscopic visualization.
    2. Incise the midline raphe from the suprasternal fossa inferiorly to the cricothyroid cartilage superiorly and expose the thyroid isthmus.
  4. Lymph node mapping and strap muscle retraction
    1. Dissect the pretracheal space to separate the thyroid isthmus from the anterior tracheal wall.
    2. Transect the thyroid isthmus using the ultrasonic scalpel.
    3. Inject 0.2 mL of nanocarbon tracer (concentration: 50 mg/mL) into the thyroid parenchyma around the target nodule to facilitate lymph node identification. Before injection, aspirate to rule out intravascular placement.
      NOTE: Potential adverse effects include mild local skin staining (usually self-resolving) and rare allergic reactions.Using a 20 mL (18 G) syringe needle as a puncture sheath can help prevent skin staining.
    4. Allow 5 min for tracer diffusion throughout the thyroid and regional lymph nodes.
    5. Perform percutaneous strap muscle suspension by passing sutures through the skin, around the strap muscles, and back out through the skin.
    6. Secure the suspension sutures to elastic traction bands and apply lateral traction to fully expose the thyroid gland.

5. Thyroid lobe mobilization and superior pole dissection

  1. Lateral thyroid dissection
    1. Dissect the space between the thyroid lobe and the sternothyroid muscle using the electrocautery hook.
    2. Extend the dissection laterally to the lateral border of the thyroid lobe.
    3. Expose the common carotid artery on the affected side.
  2. Superior pole dissection
    1. Dissect the pre-tracheal space using the electrocautery hook, deepening to the level of the Berry ligament.
    2. Identify the space between the superior pole of the thyroid and the cricothyroid muscle.
    3. Bluntly mobilize the superior lateral space of the thyroid.
    4. Ligate and divide the superior thyroid vessels close to the thyroid capsule using the ultrasonic scalpel to preserve the external branch of the superior laryngeal nerve.
      CAUTION: Exercise extreme care to avoid injury to the external branch of the superior laryngeal nerve, which runs in close proximity to the superior thyroid vessels.

6. Central lymph node dissection

  1. Central compartment exposure
    1. Retract the thyroid lobe superiorly and medially to elevate the central compartment fat and lymphatic tissue.
    2. Use the ultrasonic scalpel to divide the pretracheal fat and lymphatic tissue systematically.
  2. Lateral dissection along thyro-epiglottic ligament
    1. Identify the thyro-epiglottic ligament (ligament of Berry).
    2. Dissect the lateral thyroid space superiorly and laterally along the thyro-epiglottic ligament plane.
    3. Carefully separate and expose the inferior parathyroid gland.
    4. Preserve the blood supply to the inferior parathyroid gland by maintaining its vascular pedicle.
  3. Vagus nerve identification
    1. Use the nerve monitoring probe to explore laterally to the common carotid artery.
    2. Confirm vagus nerve signal and document baseline amplitude.
      NOTE: Continuous nerve monitoring should be employed throughout the procedure to minimize recurrent laryngeal nerve injury risk.

7. Recurrent laryngeal nerve identification and dissection

  1. Recurrent laryngeal nerve localization
    1. Use nerve monitoring forceps to perform blunt dissection medial to the inferior parathyroid gland.
    2. Identify the recurrent laryngeal nerve signal using the nerve monitoring system.
    3. Visually confirm the recurrent laryngeal nerve location.
      NOTE: The recurrent laryngeal nerve typically runs in the tracheoesophageal groove but anatomical variations exist. Always confirm nerve location with both visual identification and nerve monitoring.
  2. Recurrent laryngeal nerve tunnel creation
    1. Establish a safe dissection tunnel around the recurrent laryngeal nerve.
    2. Divide the lateral vascular fascia tissue using the ultrasonic scalpel while maintaining clear visualization of the nerve.
    3. Use blunt dissection forceps to gently mobilize the recurrent laryngeal nerve inferiorly, creating space between the esophagus and the posterior thyroid capsule.
      CAUTION: When using the ultrasonic scalpel near the recurrent laryngeal nerve, maintain a minimum distance of 3–5 mm. Activate the device only when the blade is clearly visible and avoid blind activation. Use the blunt side away from the nerve when possible.
  3. Superior dissection of the recurrent laryngeal nerve
    1. Continue dissecting the recurrent laryngeal nerve superiorly along its course.
    2. Follow the nerve to its entry point into the larynx at the level of the cricothyroid joint.
    3. Carefully identify and preserve the superior parathyroid gland along the thyroid capsule.
    4. Separate the superior parathyroid gland from the thyroid while preserving its blood supply.

8. Thyroid lobe resection

  1. Berry ligament division
    1. Gently retract the recurrent laryngeal nerve inferiorly using blunt dissection.
    2. Divide the thyroid Berry ligament using the ultrasonic scalpel under direct visualization of the recurrent laryngeal nerve.
    3. Expose the entry point of the recurrent laryngeal nerve into the larynx.
  2. Posterior thyroid dissection
    1. Retract the thyroid lobe anteriorly and superiorly.
    2. Identify and divide the posterior branch of the superior thyroid artery close to the posterior thyroid capsule using the ultrasonic scalpel.
    3. Complete the mobilization of the thyroid lobe from all attachments.
  3. Specimen removal
    1. Place the resected thyroid lobe and central compartment lymph node tissue into a sterile specimen retrieval bag.
    2. Remove the specimen bag through the camera port (ipsilateral areola incision).
    3. If necessary, extend the areolar incision slightly to facilitate specimen removal.
      NOTE: The trans-areolar location allows for incision extension with excellent cosmetic concealment.

9. Parathyroid gland assessment and hemostasis

  1. Nerve function verification
    1. Re-explore and confirm the recurrent laryngeal nerve signal using the nerve monitoring probe.
    2. Verify vagus nerve signal to ensure nerve integrity.
    3. Document final nerve monitoring amplitudes for comparison with baseline values.
    4. If loss of signal (LOS) occurs in the recurrent laryngeal nerve during monitoring, apply the following algorithm:
      1. Pause dissection immediately.
      2. Verify electrode placement and nerve integrity,
      3. Consider staging the contralateral lobectomy if the ipsilateral LOS is confirmed.
      4. Evaluate the need for conversion to open surgery. Document LOS and inform the patient postoperatively.
  2. Parathyroid viability assessment
    1. Inspect both the inferior and superior parathyroid glands for adequate blood supply.
    2. Assess parathyroid gland color and capillary refill.
    3. If parathyroid blood supply appears compromised (dark color, no capillary refill), perform immediate autotransplantation into the sternocleidomastoid muscle.
  3. Hemostasis verification
    1. Reduce the CO₂ insufflation pressure to 4 mmHg to identify any bleeding points.
    2. Achieve meticulous hemostasis using the ultrasonic scalpel or bipolar electrocautery.
    3. Irrigate the surgical field with warm saline and confirm complete hemostasis.

10. Wound closure

  1. Strap muscle reapproximation
    1. Remove the percutaneous strap muscle suspension sutures.
    2. Reapproximate the strap muscles in the midline using 4-0 barbed absorbable suture in a continuous running fashion.
  2. Drain placement
    1. Place a closed-suction drain through one of the 5 mm operating ports.
    2. Position the drain tip in the thyroid bed.
    3. Secure the drain to the skin with a suture.
  3. Port site closure
    1. Remove all trocars under direct endoscopic visualization.
    2. Close the areolar incisions with 4-0 absorbable subcuticular sutures.
    3. Close the axillary incision with 4-0 absorbable subcuticular suture.
    4. Apply sterile adhesive strips to all incisions.
  4. Compression dressing
    1. Cover the chest puncture sites with sterile gauze.
    2. Apply a chest compression band for 12 h to minimize subcutaneous fluid accumulation.

11. Postoperative care

  1. Immediate postoperative management
    1. Provide supplemental oxygen at 2–4 L/min via nasal cannula for 6 h postoperatively.
    2. Administer analgesics as needed for pain control.
    3. Provide antiemetic medication if nausea occurs.
    4. Monitor vital signs every 2 h for the first 12 h.
  2. Drain management
    1. Monitor drain output every 4 h.
    2. Remove the drain when output is < 30 mL over 24 h, typically on postoperative day 1 or 2.
  3. Laboratory monitoring
    1. Check serum calcium and parathyroid hormone levels on postoperative day 1.
    2. Supplement with oral calcium and vitamin D if hypocalcemia is detected.
  4. Discharge planning
    1. Assess patient for discharge readiness: adequate pain control, tolerating oral intake, drain removed, and stable calcium levels.
    2. Provide discharge instructions including wound care, activity restrictions, and medication regimen.
    3. Schedule a follow-up appointment for 1 week postoperatively.

12. Follow-up protocol

  1. Short-term follow-up
    1. Evaluate the patient at 1 week postoperatively to assess incision healing and remove any remaining sutures if non-absorbable sutures were used.
    2. Check thyroid function tests and adjust thyroid hormone replacement as needed.
  2. Long-term follow-up
    1. Schedule follow-up visits at 1, 3, and 6 months postoperatively.
    2. Perform thyroid function tests and neck ultrasound at each visit.
    3. For malignant cases, obtain serum thyroglobulin levels and consider radioiodine therapy based on pathology results and risk stratification.

13. Bilateral thyroidectomy (if needed)

  1. For patients requiring total thyroidectomy, mirror the same procedure to the contralateral lobe.
  2. After completing the ipsilateral lobectomy, have the surgeon and assistant reposition themselves to the opposite side. Identify and preserve the recurrent laryngeal nerve and parathyroid glands on the contralateral side using identical techniques as described above.
    NOTE: The procedure may be performed as a single-stage operation without additional port placement.

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Results

In this representative case, a 29-year-old female with a 1.2 cm papillary thyroid carcinoma in the right thyroid lobe (AJCC 8th edition stage T1aN0M0)10underwent successful CABBA-ET (Table 1). The patient expressed great cosmetic concerns and desired a scar-free neck appearance. Preoperative fine-needle aspiration confirmed papillary thyroid carcinoma. The patient met all inclusion criteria with no contraindications.

The surgical procedure (

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Discussion

The CABBA-ET technique represents a significant advancement in extra-cervical endoscopic thyroidectomy, addressing key limitations of existing approaches while maintaining oncologic safety. This protocol provides detailed, step-by-step instructions enabling accurate replication by surgeons at various experience levels.

Several steps are critical for successful CABBA-ET execution. First, precise trocar placement is essential. The ipsilateral areolar camera port must be positioned to provide opt...

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Disclosures

The authors declare that they have no competing interests or conflicts of interest related to this work.

Acknowledgements

This work was supported by the Project from Shanghai Sixth People's Hospital (grant number YNLC201905). We thank the nursing staff and anesthesiology team at Shanghai Sixth People's Hospital for their support in performing these procedures.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
10 mm 30-degree endoscopeKarl Storz26003BAStandard laparoscopic camera
4-0 barbed sutureCovidienVLOC180For strap muscle closure
Closed-suction drainAiyuanAY-Y12-G15012 French
CO2 insufflatorKarl Storz264305 20Maintains 8 mmHg pressure
Endoscopic nerve monitoring forcepsMedtronic8225490Stimulating forceps
Nanocarbon tracerChongqing LummyN/ALymph node mapping
Nerve monitoring systemMedtronicNIM 3.0Continuous monitoring
Ultrasonic scalpelEthiconHARMONIC ACEFor vessel sealing

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CABBA-ET TechniquePapillary Thyroid CarcinomaScarless ThyroidectomyParathyroid PreservationLymph Node MappingRecurrent Laryngeal NerveUltrasonic ScalpelCosmetic Outcomes
A Novel Contralateral Axillo-Bilateral-Breast Approach for Endoscopic Thyroid Surgery
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