A Novel Contralateral Axillo-Bilateral-Breast Approach for Endoscopic Thyroid Surgery
July 28th, 2026
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.
In this video, we demonstrated a novel endoscopy thyroid surgery via parallel approach. The patient is a 13 years old young female and with wider thyroid tumor. Ultrasound shows that TI-RADS 4B classification and fine-needle aspiration pathology confirmed papillary thyroid carcinoma.
The surgical video has been provided by the Ethics Committee of our hospital for educational purpose. Let's begin with surgical positioning. The patient is placed in a supine position.
The surgeon stands on the patient's left side, the assistant on the right, and the endoscope monitor is positioned at the patient's head. For this right thyroid tumor, we make a 12-millimeter incision around the right areola. This serves as our endoscopic entry port.
Then, an eight millimeter incision around the left areola and another eight millimeter incision along the skin lines of the left anterior axillary line. We create a subcutaneous space using blunt needle expansion, then continue dissection just above the platysma, extending superiorly to the thyroid cartilage and laterally to the sternocleidomastoid. The linea alba is identified and we incise it from the suprasternal fossa to the cricoid cartilage exposing the isthmus.
After dissecting the pretracheal space, we transect the isthmus with the ultrasonic scalpel. A 0.2 milliliter injection of nanocarbon tracer is then delivered around the nodule to enable lymph node mapping. We wait five minutes for diffusion, then suspend the strap muscles laterally using percutaneous traction sutures to fully expose the thyroid gland.
Moving to the superior pole, we dissect the pretracheal space down to the Berry ligament. We identify the space between the thyroid and the cricothyroid muscle. And after blunt mobilization, we ligate and divide the superior thyroid vessels close to the capsule.
Lifting the central compartment fat and lymphatic tissue, we identify the thyroepiglottic ligament and dissect along its plane. We then use the nerve monitor to identify and document the vagus nerve signal. The recurrent laryngeal nerve is located.
We create a safe dissection tunnel around the nerve, dividing the lateral vascular fascia with the ultrasonic scalpel. The inferior parathyroid gland is carefully exposed. The superior parathyroid gland is identified, separated from the thyroid, and preserved with its blood supply intact.
Under direct vision, we divide the Berry ligament with the ultrasonic scalpel. The resected lobe and central lymph nodes are placed into a sterile retrieval bag. We reconfirm the recurrent laryngeal nerve signal.
We inspect the parathyroid glands for viability, assessing color and capillary refill. The traction sutures are removed and the strap muscles are re-approximated in the midline with a 4-0 barbed absorbable suture. A closed suction drain is placed through one of the five-millimeter ports into the thyroid bed.
Postoperatively, the operation time was 85 minutes. Drainage was 45 milliliters on the first day and 30 milliliters on the second day. In our series of 130 consecutive CABBA-ET procedures performed between 2019 and 2025, the technique demonstrated consistent safety and efficacy.
Operative outcomes showed a mean surgical time of 95 minutes and a mean hospital stay of 2.3 days. No cases of postoperative hemorrhage requiring re-operation occurred. Transient recurrent laryngeal nerve palsy occurred in three patients.
No chest wall skin burns or CO2 emphysema complications occurred. Patient satisfaction surveys using a cosmetic visual analog scale conducted at six months postoperatively revealed significantly higher cosmetic satisfaction scores in the CABBA-ET group. In conclusion, the protocol demonstrated that CABBA-ET is a safe, feasible, and cosmetically safer alternative to conventional thyroidectomy for appropriately selected patient.
The detailed, step-by-step instruction provides hiring, enable, or curate replication for this technique. Potentially explain access to scar-free thyroid surgery for patients worldwide. Thank you.
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Overview
This article presents a novel endoscopic thyroidectomy technique known as the contralateral axillo-bilateral-breast approach (CABBA-ET). The protocol aims to address cosmetic concerns associated with traditional open thyroidectomy by utilizing trans-areolar and axillary incisions, resulting in concealed scars and improved patient satisfaction. The technique demonstrates operative safety and efficacy comparable to conventional methods, with superior cosmetic outcomes in a cohort of 130 patients.
Key Study Components
Area of Science
- Endocrine surgery
- Minimally invasive surgery
- Surgical oncology
Background
- Thyroid cancer incidence is rising globally.
- Open thyroidectomy often leaves visible neck scars, leading to cosmetic concerns.
- Minimally invasive and endoscopic approaches are being developed to improve cosmetic outcomes.
- Existing endoscopic techniques may have limitations in patient positioning and scar concealment.
Purpose of Study
- To describe and demonstrate the CABBA-ET technique for thyroidectomy.
- To evaluate the safety, feasibility, and cosmetic outcomes of this approach.
- To provide a detailed, replicable protocol for surgeons.
Methods Used
- Patient placed in supine position without leg separation.
- Trans-areolar and axillary incisions for endoscopic access.
- Subcutaneous space created and dissection performed above the platysma.
- Use of ultrasonic scalpel, nanocarbon tracer for lymph node mapping, and nerve monitoring.
- Preservation of parathyroid glands and recurrent laryngeal nerve.
- Postoperative assessment of drainage, complications, and cosmetic satisfaction.
Main Results
- Mean operative time: 95 minutes; mean hospital stay: 2.3 days.
- No cases of postoperative hemorrhage requiring re-operation.
- Transient recurrent laryngeal nerve palsy in three patients; no permanent complications.
- No chest wall skin burns or CO2 emphysema observed.
- Significantly higher cosmetic satisfaction scores compared to conventional thyroidectomy.
Conclusions
- CABBA-ET is a safe and feasible alternative to conventional thyroidectomy for selected patients.
- The approach offers superior cosmetic outcomes with concealed scars.
- The protocol is replicable and may expand access to scar-free thyroid surgery worldwide.
Frequently Asked Questions
Executive Industry Relevance
Minimally invasive surgical innovations like the contralateral axillo-bilateral-breast approach (CABBA-ET) for thyroidectomy address the growing demand for procedures that minimize visible scarring and postoperative complications. For biopharma R&D, such techniques enable more precise anatomical access, facilitate nerve and gland preservation, and support the development of advanced perioperative monitoring tools. These advances are relevant for device validation, surgical workflow optimization, and translational research in endocrine oncology.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise anatomical dissection for functional mapping of nerves and glands.
- Supports validation of intraoperative nerve monitoring and tracer-based lymph node mapping.
- Facilitates mechanistic de-risking by preserving critical structures during resection.
Screening & Assay Development
- Provides a reproducible surgical model for evaluating perioperative device performance.
- Standardizes operative field exposure, supporting quantitative assessment of surgical outcomes.
- Enables collection of high-quality tissue samples for downstream molecular assays.
Translational & Preclinical Research
- Aligns with disease-relevant models for papillary thyroid carcinoma and benign nodules.
- Supports continuity from surgical innovation to preclinical device and biomarker validation.
- Reduces confounding variables in studies of postoperative recovery and complication rates.
Pipeline & Workflow Integration
CABBA-ET integrates into the surgical innovation pipeline from early device validation through translational research in endocrine oncology.
- Discovery Biology: Facilitates hypothesis testing on nerve preservation and lymphatic mapping in thyroid surgery.
- Screening: Provides a standardized operative platform for evaluating intraoperative monitoring technologies.
- Analytics: Enables quantitative measurement of operative time, complication rates, and cosmetic outcomes.
- Translational Research: Bridges surgical technique development with preclinical validation of perioperative interventions.
- Enterprise Reuse: Establishes a replicable protocol for multi-center studies and device benchmarking.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in nerve and gland preservation outcomes.
- Operational Value: Standardizes surgical workflow and reduces variability in cosmetic results.
- Strategic Value: Improves patient satisfaction metrics and supports adoption of minimally invasive techniques.
- Portfolio Impact: Enables risk-adjusted advancement of surgical devices and perioperative monitoring solutions.
Implementation Considerations
- Requires expertise in endoscopic thyroid surgery and intraoperative nerve monitoring.
- Needs access to specialized endoscopic instruments and nerve monitoring systems.
- Demands cross-team standardization for operative field exposure and tissue handling.
- Adaptation may be limited to patients with small papillary carcinomas or benign nodules.
- Operative safety and cosmetic outcomes must be validated in diverse patient populations.