Comment on “Preliminary report on a novel technique for endoscopic transaxillary thyroidectomy: a case–control study”

Advances in laparoscopic technology have spurred the development of various endoscopic thyroidectomy approaches, including the total areolar approach, gasless axillary approach, infraclavicular approach, transoral approach, and robotic-assisted techniques[1]. In recent years, multiple studies have confirmed that gasless transaxillary endoscopic thyroidectomy (GTET) is comparable to conventional open thyroidectomy in terms of therapeutic efficacy and safety[2–4], making it a safe and viable option for patients with cosmetic concerns. We recently read with great interest the article by Liu et al[5], entitled “Preliminary report on a novel technique for endoscopic transaxillary thyroidectomy: a case–control study.” This case–control study introduced a novel endoscopic transaxillary thyroidectomy technique, which is characterized by a shorter incision length and a smaller dissection area compared to conventional GTET. The procedure appears to be both feasible and safe, holding certain clinical value. Despite these advantages, several issues warrant further discussion. This correspondence was developed following the TITAN Guidelines 2025(2) for the declaration and use of artificial intelligence in scholarly publishing. No AI tools were employed in the conception, design, analysis, interpretation, or writing of this work[6]. First, Liu et al stated in their discussion that the subcutaneous flap area in their novel axillary approach accounts for only 27% of that in conventional gasless transaxillary thyroidectomy (as measured using ImageJ software). This claim raises our concern. Given that both techniques utilize an axillary incision and must access the same fixed surgical target – the inferior pole of the thyroid gland, the entire central lymph node compartment (tracheal rings 2–4, carotid sheath, and the full length of the recurrent laryngeal nerve), and the prevertebral fascial plane – the anatomical boundaries of the Liu method and the classic GTET differ by less than 0.5 cm in all directions. Even in planar geometry, such minor differences could not accumulate to a 70% reduction in surface area, let alone in the curved anatomical structure of the supraclavicular fossa. ImageJ only provides two-dimensional projections, rather than patient-specific, three-dimensional, anatomically bounded areas. The study did not specify fixed osteo-muscular anatomical landmarks, perform blinded remeasurements, provide patient-level 3D coordinates, report the dissected flap area in cm2 ± standard deviation, present a 95% confidence interval for the area difference, or predefine a non-inferiority margin. Therefore, we express skepticism regarding the authors’ conclusion that the novel technique significantly reduces the dissected flap area compared to the conventional approach. Second, the authors suggested that the smaller dissection area in the novel technique may help reduce postoperative sensory loss and pain. However, we have reservations regarding the reported significant reduction in flap area. Moreover, sensory loss and postoperative pain in axillary approach endoscopic thyroid surgery are closely associated with injury to the supraclavicular nerves. The article did not provide a detailed comparison of supraclavicular nerve injury between the novel and conventional axillary approach groups. Lastly, although the authors replaced the use of a special retractor with subcutaneous sutures for muscle lifting, this does not necessarily imply reduced muscle trauma. A smaller area of muscle lifting might, in fact, result in greater traction force per unit area. Third, beyond the reported differences in age, gender, and tumor pathology between the open and endoscopic groups, the study design exhibits issues related to the control group. The GTET group included only 42 cases, representing just 36% of the Novel group’s sample size. This limited sample may lead to insufficient statistical power and a high risk of false-negative results. Furthermore, the substantial differences in pathological composition among the groups hinder meaningful comparisons of oncological outcomes, such as the number of lymph nodes dissected or recurrence rates, thereby impeding the broader adoption of this novel technique. Fourth, although thyroid tumors generally have a favorable prognosis, the article assessed the safety of the novel procedure solely based on 30-day postoperative complications. The follow-up duration is too short, with no median follow-up months or range provided, making it impossible to evaluate oncological safety or scar hyperplasia. Fifth, the conclusion that the novel technique offers a “shorter scar and better cosmesis” lacks objective supporting evidence. While the authors reported incision lengths of 2 cm (Novel group) versus 5–6 cm (GTET group), they did not provide postoperative photographs at 6 or 12 months, blinded cosmetic assessments, or follow-up evaluations using validated scales. Finally, despite the aforementioned limitations, we sincerely appreciate the contributions of the authors. This study offers a new direction for innovation in axillary approach thyroid surgery.