I would like to thank Dr. Dionigi et al. for their interest in our paper entitled “Robotic Thyroidectomy by Gasless Unilateral Axillo-Breast or Axillary Approach: Our Early Experiences” [1]. I agree with their commentary. Endoscopic or robotic thyroidectomy by gasless unilateral axillo-breast or axillary approach is not minimally invasive thyroid surgery [2, 3]. It is more invasive than conventional open thyroidectomy. The area dissected to expose the thyroid gland, the amount of drainage, and postoperative pain were more than with open thyroidectomy [1, 3].

The complication rate is similar with conventional open thyroidectomy in experienced surgeons [3–5]. However for the learning curve, the rate of recurrent laryngeal nerve palsy might be higher than open thyroid surgery due to the difficulty of the technique and the need for a period of learning. The most significant advantage of robotic or endoscopic thyroidectomy is the excellent postoperative cosmesis [1–3]. The cosmesis might be not an important concern for certain patients. However, thyroid nodules are common in young women who are very concerned about the aesthetic results of thyroidectomy. Hence, endoscopic or robotic thyroidectomy by extracervical approach is clearly indicated for the subset of patients who are very interested in the postoperative cosmesis. The indication of endoscopic or robotic thyroidectomy can be expanded to more advanced thyroid lesions with more experience. Another advantage of robotic or endoscopic thyroid surgery is that the identification and preservation of the recurrent laryngeal nerve and parathyroid gland is subjectively easy due to the magnified view.

As Dr. Dionigi’s comments, endoscopic or robotic thyroidectomy by extracervical approaches is less advantageous and effective than endoscopic abdominal and thoracic surgery. The further refinement of procedure and more advanced technology is necessary to minimize the surgical morbidity and invasiveness of robotic and endoscopic thyroid surgery.