Background and Aims Recurrent laryngeal nerve (RLN) injury during endoscopic thyroid cancer radical surgery significantly affects postoperative recovery and quality of life. Avoiding RLN injury has always been a key concern during thyroid surgeries. Choosing an appropriate and safe approach to expose the RLN in endoscopic thyroid cancer surgery may reduce the risk of RLN injury. However, the optimal approach for RLN exposure in endoscopic thyroid cancer radical surgery through the anterior chest approach remains inconclusive. This study was performed to compare the surgical outcomes of using the medial and lateral approaches to expose the RLN in endoscopic thyroid cancer surgery through the anterior chest approach, so as to provide reference for clinical practice.Methods The clinical data of 85 patients who underwent endoscopic thyroid cancer radical surgery (ipsilateral lobectomy and ipsilateral central lymph node dissection) via the anterior chest approach at Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University, from January 2020 to January 2023 were retrospectively analyzed. Among the patients, medial approach was used in 45 cases (medial approach group) and lateral approach was used for RLN exposure in 40 cases (lateral approach group). The main clinical variables were compared between the two groups.Results No statistically significant differences were found in baseline data between the two groups (all P>0.05). Both groups successfully completed endoscopic thyroidectomy via the anterior chest approach with complete RLN exposure at the main trunk and its entry into the larynx. The RLN exposure time and endoscopic surgery time in the medial approach group were significantly shorter than those in the lateral approach group (both P<0.05). Intraoperative blood loss was significantly less in the medial approach group compared to the lateral approach group (P<0.05). There were no cases of transient RLN injury in the medial approach group, whereas 5 cases of transient RLN injury occurred in the lateral approach group, with a statistically significant difference (P<0.05). The medial approach group had fewer cases of thyroid tissue residue at the Berry's ligament and transient hypoparathyroidism than the lateral approach group, but the differences were not statistically significant (both P>0.05). There were no statistically significant differences between the two groups in postoperative hospital stay or postoperative drainage volume (both P>0.05).Conclusion The medial approach for RLN exposure in endoscopic thyroid cancer surgery is safe and feasible. Compared to the lateral approach, it allows faster RLN exposure, effectively reduces the risk of transient RLN injury, decreases intraoperative blood loss and operative time, and may also reduce the incidence of transient hypoparathyroidism and thyroid tissue residue to some extent.