Papillary thyroid carcinoma is the predominant form of differentiated thyroid cancer. In patients with unilateral disease who are suitable for lobectomy, the surgeon must remove the tumor while protecting the recurrent laryngeal nerve (RLN), preserving parathyroid function, and achieving appropriate control of regional lymph nodes. Decisions about the extent of thyroid resection and central compartment dissection should follow the biological risk of the tumor, the nodal findings, preoperative imaging, and the likely need for postoperative therapy. The location of the incision should not determine the oncologic plan [1][2].

COT is familiar to most thyroid surgeons and provides straightforward access to the thyroid gland, central neck, and surrounding structures. Its main disadvantages are not usually related to tumor clearance, but to the patient’s postoperative experience. A cervical scar remains visible, and some patients report tightness, numbness, or dissatisfaction with the appearance of the neck. ET was developed partly in response to these concerns. It includes transaxillary, breast or areolar, transoral vestibular, and trans-subclavian techniques. Because these routes differ in working distance, flap dissection, use of carbon dioxide, and central-neck exposure, their outcomes should be interpreted separately rather than combined under a single label [3]-[8].

The trans-subclavian technique uses an incision below the clavicle and a mechanical lifting device to maintain a gasless working space. The route is shorter than several other remote-access approaches and gives a relatively direct path to one thyroid lobe and the ipsilateral central compartment. It also avoids an anterior cervical incision. Even so, the published experience is much smaller than that for transaxillary, areolar, or transoral surgery. This review therefore separates evidence that directly compares GETTSA with COT from broader findings on ET and aims to define where GETTSA can reasonably fit in the treatment of unilateral PTC.

This article is a structured narrative review, not a systematic review or meta-analysis. We searched PubMed and official journal websites on June 22, 2026. Search terms included combinations of “papillary thyroid carcinoma,” “unilateral,” “endoscopic thyroidectomy,” “open thyroidectomy,” “trans-subclavian,” “subclavian,” “gasless,” “transaxillary,” “areola,” “transoral,” “quality of life,” and “central neck dissection.” We first considered guidelines, followed by direct GETTSA-versus-COT studies, comparisons between GETTSA and other endoscopic routes, and systematic reviews or representative comparative studies that could place the route-specific evidence in context. Studies restricted to benign thyroid disease, robotic procedures alone, or extensive lateral-neck disease were not used as the main basis for conclusions about unilateral PTC. The aim was a focused clinical synthesis rather than an exhaustive search of every publication.

After duplicate records were removed, 150 titles and abstracts were reviewed. Twenty-one publications were retained for the final synthesis: three guidelines or consensus documents, two direct GETTSA-versus-COT cohorts, three studies comparing GETTSA with other access routes, and thirteen reports that provided broader context on ET or quality of life.

Eligible evidence included peer-reviewed guidelines, systematic reviews, randomized trials, and comparative cohorts involving adults with unilateral PTC broadly corresponding to cT1-cT2 disease. The principal comparison was limited to patients without gross extrathyroidal extension or clinically evident lateral-neck metastasis and for whom lobectomy with isthmusectomy, with or without an equivalent central compartment dissection, was an appropriate operation [1][2]. Studies centered on benign disease, robotic surgery only, total thyroidectomy, extensive lateral dissection, gross invasion, or a previously operated or irradiated neck were excluded from this comparison. Recovery and functional outcomes were considered only when follow-up reached at least 3 months. Claims concerning recurrence or oncologic durability were drawn only from reports with at least 12 months of follow-up.

COT is performed through a low transverse neck incision and provides direct visualization of the thyroid, parathyroid glands, RLN, and central compartment. The working distance is short, and the exposure can be extended quickly when bleeding, anatomical variation, or unexpected invasion is encountered. The trade-off is a visible cervical scar and the possibility of local symptoms related to skin-flap elevation and strap-muscle dissection.

Remote-access ET places the incision outside the anterior neck. Transaxillary and breast or areolar approaches hide the scar but usually require a longer working tunnel and, in some techniques, a wide subcutaneous flap. The transoral vestibular route leaves no visible skin scar, yet it enters through the oral vestibule and has different limitations regarding working space, infection risk, and specimen extraction. These route-specific features make it misleading to discuss all forms of ET as though they were the same operation [8]-[14].

GETTSA creates a gasless operative cavity through an infraclavicular incision supported by a suspension system. Several recent reports suggest that the path to the central compartment is shorter and more direct than with the transaxillary route, with less dissection across the anterior chest. In a randomized trial of 160 patients with cN0 PTC, GETTSA was associated with a shorter operation and a higher rate of complete central-compartment exposure than gasless transaxillary ET [6]. This trial compared two endoscopic methods, however, and cannot be used alone to claim equivalence between GETTSA and open surgery. Table 1 summarizes the practical differences among the approaches.

Table 1.Practical comparison of conventional open surgery and representative endoscopic access routes for unilateral PTC.

The following outcome sections distinguish three levels of evidence. The first consists of direct comparisons between GETTSA and COT [3][4]. The second includes studies comparing GETTSA with another endoscopic route [5]-[7]; these clarify technical differences but do not establish equivalence with open surgery. The third is the broader ET literature [8]-[20], which is useful for context but only indirectly informs the trans-subclavian approach. Conclusions about GETTSA versus COT are based mainly on the direct evidence.

The literature supports short-term technical feasibility and acceptable oncologic surrogate outcomes, but it does not establish long-term equivalence. In selected unilateral PTC, similar central-node yields, positive-node counts, low early recurrence rates, and no obvious excess of short-term complications are reassuring. PTC commonly follows an indolent course, however, so follow-up measured in months or only a few years cannot determine non-inferiority for structural recurrence, reoperation, or disease-specific survival. This uncertainty is especially important for GETTSA because direct comparisons with COT have appeared only recently [3]-[5].

Another difficulty is that the endoscopic and open groups may receive more than a different incision. Policies for prophylactic central dissection, carbon nanoparticle use, intraoperative nerve monitoring, parathyroid autofluorescence, energy devices, and postoperative surveillance can all affect the measured outcomes. In the cohort reported by Yang et al., several adjuncts differed between groups, so the comparison represented two broader surgical strategies rather than access route alone [3]. The evidence should therefore not be summarized as showing superior oncologic clearance or lower permanent complication rates with ET.

On present evidence, GETTSA is a reasonable elective option for selected patients with unilateral low-risk PTC and for carefully chosen patients with intermediate-risk disease, provided that the same oncologic operation can be completed without compromise. Typical candidates have a tumor confined to one lobe, no gross invasion, and no clinically apparent lateral-neck metastasis requiring a formal lateral dissection. Favorable neck anatomy and body habitus are also helpful. Patients need to understand that the cervical scar is avoided at the cost of an infraclavicular incision and, in most series, a longer operation. The procedure should be undertaken by surgeons experienced in open thyroid surgery who are prepared to convert when exposure or completeness becomes uncertain.

GETTSA may appeal particularly to patients who strongly wish to avoid an anterior neck scar but do not want a transoral procedure. Early comparisons with the transaxillary route suggest a shorter working corridor, better access to the central compartment, and fewer early chest-wall symptoms [5]-[7]. These potential advantages do not justify extending the indication to grossly invasive tumors or extensive nodal disease. COT remains the more dependable choice for bulky, high-risk, reoperative, irradiated, or anatomically complex cases.

The evidence has several recurring weaknesses. Most studies are observational reports from a single center, and patients often selected their preferred operation. Eligibility criteria, policies for central-neck dissection, energy devices, and definitions of complications were not consistent. Cosmetic and quality-of-life results are also vulnerable to expectation and performance bias. Finally, follow-up is generally too short to support reliable conclusions about long-term oncologic outcomes. Matching and multivariable adjustment reduce some of these problems but cannot remove them.

ATA and AAES guidance is consistent with a selection-and-capability approach: remote access should not alter the required oncologic operation, the choice should follow informed shared decision-making, and the technique should be offered only by teams able to manage complications and convert safely to a standard operation [1][21]. To make results comparable across institutions, studies should describe patient selection, the exact extent of surgery, the experience of the team, and the reason for every conversion.

Future research should document the exact thyroid and nodal procedures, preoperative and postoperative laryngoscopy, standardized RLN and calcium outcomes, accidental parathyroid excision, autotransplantation, validated patient-reported measures such as THYCA-QoL, direct costs, the stage of the learning curve, conversion criteria, and medium- or long-term structural follow-up. Multicenter prospective registries and direct comparisons with COT would add more value than further small retrospective series from a single route. For GETTSA, the next question is no longer whether the scar can be hidden, but whether safety and oncologic completeness can be reproduced across surgeons and centers.

For appropriately selected unilateral PTC, ET can provide acceptable short-term surgical and nodal outcomes while moving the scar away from the anterior neck. COT nevertheless remains the reference procedure because it offers direct exposure, versatility, and the widest oncologic applicability. GETTSA provides a relatively short gasless route to the unilateral thyroid and central compartment, and recent comparisons suggest advantages in scar-related satisfaction and some functional outcomes. These benefits support its use as an experience-dependent alternative for selected patients. They do not yet justify replacing open thyroidectomy or claiming oncologic equivalence beyond the short to medium term.

This work received no external funding.

Lei Tang and Chuanchang Yin developed the review concept. Lei Tang designed the literature approach and prepared the first draft. Chuanchang Yin critically revised the manuscript and supervised the work. Both authors approved the final version.

This narrative review used only previously published, publicly available studies and included no new participants, identifiable information, or original patient-level data. Ethics committee approval and informed consent were therefore not required.

No original dataset was created or analyzed. The evidence discussed in this review is available in the cited publications.

*First author.

^#Corresponding author.