A modified approach (Figure 
injury to the superior laryngeal nerve, tumor, numbness, sternal head of the SCM, Sternal and clavicular
SEPARATION, TUMOR, CAVITY
Modified gasless trans‐axillary endoscopic thyroidectomy. (A) Patient positioning and incision markings. (B) The lateral border of the pectoralis major muscle is exposed. (C) Positioning of the trocars and modified retractor during surgery. (D) Sternal and clavicular heads of the sternocleidomastoid muscle (SCM). (E) The sternal head of the SCM is lifted. (F) Exposure of the omohyoid muscle. (G) Exposure of the recurrent laryngeal nerve (black arrow) and inferior thyroid artery (blue arrow). (H) Exposure of the superior parathyroid gland (green arrow). (I) Protecting the recurrent laryngeal nerve using a wet gauze. (J) Modified version of the retractor. (K) Postresection of the thyroid gland and central neck lymph nodes. (L) Traditional version of the retractor.The patient was placed in a supine position with one arm extended at <90° to expose the incision site at the axilla. An incision site is chosen at an appropriate natural axillary fold without exceeding the anterior axillary line. The positions of two 5 mm trocars are 2 cm exterior to the midclavicular line—one inferior to the clavicle and the second 5 cm below the first (A).The surgical site is disinfected and draped accordingly, an incision is made, and subcutaneous fat is cut to expose the upper lateral border of the pectoralis major muscle (B). The fascia on the pectoralis major is preserved, and the surgical cavity is extended using a long head electric knife to exceed the premarked position of the two trocars by 2 cm. The modified retractor is placed in the surgical cavity from the axillary incision site, and the two trocars are inserted at the premarked positions. The video camera is inserted from the axillary incision, and one 5‐mm instrument is placed in each trocar (C). An ultrasonic scalpel is used to extend the subcutaneous cavity. The exterior jugular vein and the supraclavicular nerve should be carefully protected during this step. Injury to the supraclavicular nerve will cause numbness around the supraclavicular area. The position of the retractor is constantly adjusted to facilitate the exposure of the sternocleidomastoid muscle. The sternal and clavicular heads of the sternocleidomastoid muscle are identified, and the two bundles of tissues are separated along their natural gap (D). The retractor is adjusted to lift the sternal head of the sternocleidomastoid muscle (E). The omohyoid muscle is then exposed, followed by the internal jugular vein. The omohyoid muscle is preserved, and the strap muscle inferior to the omohyoid muscle is exposed (F). The lateral border of the strap muscle is exposed, and precautions are taken to prevent injury to the internal jugular vein and carotid artery. At this point, the thyroid gland will be visible.The retractor is adjusted to lift the strap muscle and part of the thyroid gland, and the central neck lymph nodes are exposed (G). The recurrent laryngeal lymph node is exposed through blunt separation. The inferior thyroid artery and the inferior parathyroid glands are identified during this step. The pathway of the recurrent laryngeal nerve to its entry into the larynx is bluntly separated. The inferior thyroid artery and middle thyroid vein are coagulated at multiple points and dissected. The borders of central neck lymph nodes range from the medial edge of the carotid artery, the suprasternal fossa, the prevertebral fascia, and the midline of the trachea. The central lymph nodes are dissected along their lateral, lower, deep, and middle borders, thus performing en bloc resection. For inferior parathyroid glands that are difficult to preserve in situ, auto‐transplantation in the upper lateral edge of the pectoralis major muscle is performed and marked with nonabsorbable sutures,The isthmus is exposed by separating the strap muscle from the thyroid gland and dissected. The retractor is further adjusted to expose the superior pole to the thyroid gland. The thyroid gland's superior blood vessels are coagulated at multiple points and dissected. Care is taken to avoid injury to the superior laryngeal nerve. At this point, we can identify the superior parathyroid gland (H), and a “decapping” method of the superior pole of the thyroid gland allows careful preservation of the parathyroid glands' fascia and blood vessels.At this point, the suspensory ligaments of the thyroid remain to be processed. A wet rolled gauze protects the recurrent laryngeal nerve (I), and the suspensory ligaments are progressively dissected. The thyroid gland, along with the central neck lymph nodes, is placed in a specimen bag and removed from the incision at the axilla to reduce the risk of thyroid and tumor implantation.The differences between the traditional and modified approaches: (1) A better‐concealed incision further away from the anterior axillary line for the modified approach. (2) A smaller incision at the axilla using a retractor we designed. (3) Two trocar incisions were made for the modified approach; on the contrary, only one trocar is placed inferior to the axillary incision for the traditional approach.