Critical Landmark Exposure & Anatomical Recognition and Axillo-Breast Lateral Entry: Endoscopic Thyroidectomy

Abstract

Background: Minimally invasive thyroidectomy has evolved to improve cosmetic outcomes while maintaining surgical safety. The axillo-breast approach is increasingly favored, yet standardized methods to enhance anatomical clarity and nerve preservation are limited. Objective: To describe the Axillo-Breast Lateral Entry (ABLE) technique for endoscopic hemithyroidectomy and introduce the Critical Landmark Exposure & Anatomical Recognition (CLEAR) concept for safer dissection. Materials and Methods: A retrospective review was conducted on 40 patients who underwent ABLE endoscopic hemithyroidectomy without intraoperative neuromonitoring between January 2023 and October 2025 at a tertiary centre in Northern India. Standard laparoscopic instruments and energy devices were used. Port placements followed ergonomic principles. The CLEAR view was applied to reliably identify key structures: recurrent laryngeal nerve (RLN), inferior thyroid artery (ITA), and parathyroid glands within a defined anatomical triangle. Results: All patients had benign nodules with a mean size of 4.4 ± 1.2 cm. The RLN was visually identified in 100% of cases. There were no instances of permanent vocal cord palsy or hypoparathyroidism. All patients were discharged by postoperative day one, with excellent cosmetic outcomes and no major complications. Conclusion: The ABLE technique is safe, reproducible, and ergonomically favorable, particularly for early-career surgeons. The CLEAR concept provides a consistent anatomical framework for preserving critical structures, especially when intraoperative neuromonitoring is not available. This approach may facilitate wider adoption of endoscopic thyroidectomy in resource-limited settings.

Keywords: endoscopic neck surgery; endoscopic surgery techniques; endoscopic thyroidectomy; minimally invasive thyroid surgery; thyroidectomy.