1. Size first: 4 cm is the cut-off
- Benign nodules or papillary cancers ≤4 cm, intact capsule, no airway/nerve/vessel invasion
→ An endoscopic approach (trans-oral TOETVA, axillary, areolar, etc.) gives the same quality of lobectomy plus central-compartment dissection; six-month recurrence rates are identical to open surgery. - Tumours >4 cm, multifocal lesions kissing the recurrent laryngeal nerve, gross extrathyroidal extension or bulky lateral-neck nodes
→ Open operation gives a wider view, safer handling and a lower chance of “leaving disease behind”.
2. Patient second: can you tolerate CO₂ insufflation and a sub-cutaneous tunnel?
Green light
- Age 18–60, BMI <30, no significant cardiopulmonary disease
- No prior neck irradiation, no mandibular or oral cavity deformity
→ Cosmetic benefit delivered: 3–4 day stay, no visible neck scar.
Red light
- COPD, coronary disease, obesity (risk of hypercarbia under CO₂ pneumo-space)
- Chest-wall deformity, adolescents (difficult working space)
→ Open surgery is safer and faster.
3. Hospital third: is the gear—and the team—there?
- Endoscopic: needs dedicated instruments, CO₂ insufflator, and a 30–50-case learning curve; total cost ≈ 8–12k RMB higher.
- Open: available in every grade-A hospital, widest insurance coverage.
One-sentence decision table
| ≤4 cm, low-risk, high cosmetic demand, fit patient, experienced team | → Go endoscopic |
|---|---|
| >4 cm, high-risk, bulky nodes, obese/cardiopulmonary compromise | → Go open |
Whichever route you take, book a serum thyroid function + neck ultrasound at one month and keep up with calcium/L-T₄ exactly as prescribed—that last step locks in long-term quality of life.