[Abstract] OBJECTIVE: To investigate the feasibility and safety of laparoscopic thyroidectomy via thoracic route. METHODS: Thirty-six cases of laparoscopic thyroidectomy via the transthoracic route with anterior sternal approach were retrospectively analyzed, and the indications for laparoscopic thyroidectomy, surgical methods, and therapeutic efficacy of laparoscopic thyroidectomy were discussed. RESULTS: Thirty-five cases of laparoscopic thyroidectomy were successfully performed, with an average operative time of 105 min, an average postoperative hospitalization time of 5.2 d (4-7 d), no nerve or parathyroid injury and other complications, and one case was referred to open surgery. Conclusion: Trans-thoracic pathway lumpectomy for thyroidectomy is safe and feasible, with no scar in the neck and small and hidden scars in the chest after the operation, and the advantages of cosmetic effect are obvious, which is worth to be popularized for clinical application. With the accumulation of experience and the continuous improvement of instruments, laparoscopic surgery is no longer limited to the original cavity in the body, such as the abdominal cavity, and has begun to develop to the potential cavity or no cavity area. 1997 Hüscher et al. first introduced laparoscopic technology into the thyroid surgery, and successfully carried out adenohypophyseotomy [1], laparoscopic thyroidectomy has changed the tradition of the incision in the neck, and the surgical incision was minimized and hidden, to achieve the nakedness of the neck. The procedure has been unanimously recognized as the most valuable because it hides the surgical incision and achieves the aesthetic effect of no surgical scar on the exposed neck [2-3]. However, due to the complex anatomy of the neck, rich blood supply of the thyroid gland, the surrounding neighborhood of important organs such as neurovascular, and no natural surgical space in the neck, the surgical operation is quite difficult, we have carried out laparoscopic thyroid surgery since 2005, and so far a total of 36 cases have been admitted, and satisfactory results are summarized in the following report. 1, Data and Methods 1.1 General information of this group of 36 cases, 9 men, 27 women, the average age of 31.5 years (19-54 years). The main complaint was the discovery of anterior cervical masses ranging from several days to several months, with different sized masses palpable in the anterior cervical region, smooth surface, clear boundary, and can move up and down with swallowing. The preoperative color ultrasound localization was clear, the size of 1-4cm, 21 cases were single, 8 cases were unilateral multiple, 7 cases were bilateral. According to the color ultrasound results, all of them were considered benign tumors, and there were no enlarged lymph nodes in the neck. 1.2 Surgical method General anesthesia with endotracheal intubation. The patient took the supine position with legs apart and neck and shoulder slightly padded. Saline 500 plus epinephrine 1 dominate to make “expansion liquid”, in the anterior chest pre-creation of space area for subcutaneous injection. A 1.2-cm transverse incision was made in the middle of both nipples, and a homemade non-invasive puncture rod was used to puncture and separate the superficial surface of the deep fascia, establish a channel for lens placement, and place a 30-degree lumenscope with a trocar; the purse was sutured to close the incision, tighten the purse to prevent leakage of gas and fix the trocar, and then fill it with carbon dioxide gas at a pressure of 6 mm Hg. A small incision was then made in the upper edge of the left and right areolas, and the left and right areola were each incised with a 0.5-cm small incision with a non-invasive puncture rod. A non-invasive puncture rod was used to puncture and separate the subcutaneous loose connective tissue toward the thyroid gland, establish a subcutaneous channel, place a 0.5-cm trocar and insert surgical instruments and an ultrasonic knife, respectively. The subcutaneous loose connective tissue was separated with the ultrasonic knife under direct luminal microscopic vision, as close to the thoracic fascia as possible. The separation was continued along the deep surface of the vastus cervicis muscle to the plane of the superior border of the thyroid gland. After determining the location of the thyroid gland by in vitro palpation, the ultrasonic scalpel was used to cut through the white line of the neck, cut off the subungual muscle group transversely if the tumor was larger than 3 cm, and cut through the outer layer of the thyroid gland longitudinally to reveal the thyroid gland carefully, and then bluntly separate the surrounding tissues along the true peritoneum of the thyroid gland to fully reveal the gland and the protruding tumor, and then combined with the preoperative ultrasound localization, the scope of the resection was decided. The ultrasonic knife is operated with slow power to directly remove the nodule. If lobectomy is to be performed, the periphery of the lobes will be bluntly separated with a stripping rod, and the inferior thyroid artery, middle vein and superior thyroid artery will be cut off with the ultrasonic scalpel by pressing against the gland, the isthmus of thyroid will be cut off longitudinally, and then the lower pole of thyroid will be removed from the lower part of thyroid by pressing against the peritoneum of thyroid gland from bottom to top. The resected specimen was placed in a specimen bag and removed from the middle incision. Frozen sections were routinely sent intraoperatively. 1 case of papillary thyroid carcinoma, which did not invade the peritoneum, was performed with lobectomy + isthmus resection and carotid sheath lymph node dissection. After flushing the surgical field without obvious blood seepage, the cervical white line and subglottic musculature were sutured, and a drainage tube with side holes cut (we chose common infusion tube) was inserted from the subglottic musculature to the thyroid incision, and then the drainage tube was led out from the lesion on the opposite side or bilateral areola incision, connected with negative pressure suction device, and the operative area was bandaged with pressure. 2, Results In this group, 35 out of 36 patients successfully completed laparoscopic thyroid surgery by anterior sternal approach, the operation time was 90-165 minutes, average 105 minutes, intraoperative bleeding was 30-60 ml, average 40 ml,, postoperative pathology of thyroid adenomas in 23 cases, nodular goiter in 12 cases, and thyroid cancer in 1 case. The patient with thyroid cancer was followed up for 17 months without recurrence or metastasis. Postoperative wound drains were removed when the daily dose was less than 10 ml, and were usually placed for 48-72 hours, and the patients were discharged from the hospital 4-7 days after surgery, with an average of 5.2 days. 2 of the 35 cases had a slight borderline of the neck muscles after surgery, which recovered very quickly after physiotherapy, and there was no case of nerve injury, no hissing or choking, no parathyroid gland injury, no hemorrhage, and no mediastinal emphysema and other serious complications, and the patients were very satisfied with the results of the surgery, especially the cosmetic effect. One case was a tumor in the upper pole of the left thyroid gland, about 4 cm in size, it was difficult to reveal the upper pole blood vessels during the operation, there was a small blood vessel tear and bleeding during the operation, it was not possible to stop the bleeding under direct vision, in order to prevent accidental injury, it was converted into an open surgery, the operation went smoothly, there was no postoperative complication. 3, Discussion Luminal thyroidectomy we adopted the three-hole method introduced by Ishii et al [4] and improved it, from the chest approach, the surgical operation space is large, not only the neck is completely free of scars, but also a wide range of indications for the operation, compared with the transaxillary approach, is more suitable for bilateral thyroid tumors, and there are no major complications occurred. On the one hand, it has excellent cosmetic effect and meets the patient’s psychological requirements. On the other hand, we used preoperative subcutaneous injection of saline with epinephrine and intraoperative application of ultrasonic knife to stop hemorrhage, which significantly reduced bleeding. Due to less bleeding and the magnifying effect of endoscopy, the local anatomical structure is very clear, and the recurrent laryngeal nerve and parathyroid glands can be clearly exposed, so as long as the operation is done properly, very few injuries will occur, and the complication rate is not high. Minimally invasive aims are achieved by reducing the sum of physical and psychological trauma [5]. We grasp that the indications for laparoscopic thyroidectomy include benign diseases such as simple goiter, nodular goiter or with cystic hyperplasia, thyroid adenoma, etc., which are not well treated by internal medicine. Try to choose nodular