Background and Aims In recent years, with the continuous advancement of minimally invasive technology and the increasing demand for quality of life, endoscopic thyroid surgery has gradually become popular and is particularly favored by young female patients. For middle-aged and elderly patients, open surgery still dominates in clinical practice, and many patients may experience postoperative complications such as flap sagging, swallowing difficulties, and foreign body sensation, which can significantly impact their daily lives. The gasless transaxillary endoscopic thyroid surgery technique utilizes the natural gaps between neck muscles to create a working space, allowing for exposure and surgical manipulation of the thyroid gland beneath the deep surface of the sternocleidomastoid muscle. This approach has minimal impact on neck function and does not require CO₂, resulting in reduced effects on the cardiovascular and respiratory systems. This study aims to explore the efficacy and safety of gasless transaxillary endoscopic thyroid surgery in middle-aged and elderly patients, providing a reference for its application in this patient population.Methods The clinical data of 56 middle-aged and elderly patients with thyroid cancer admitted to the First People's Hospital of Suqian from January 2021 to June 2022 were retrospectively analyzed. Among them, 26 cases underwent gasless transaxillary endoscopic thyroid surgery (observation group), and 30 cases underwent traditional open surgery (control group). The surgical variables, pain status, neck injury index, swallowing disorder index, complications, and prognosis were compared between the two groups of patients.Results All 56 patients successfully underwent the surgery. The observation group had longer operative time and higher postoperative drainage volume compared to the control group (both P<0.05). There were no statistically significant differences between the two groups in terms of intraoperative bleeding, dyspnea, hoarseness, numbness in the extremities, coughing while drinking, subcutaneous hematoma, the number of resected central lymph nodes, and length of hospital stay (all P>0.05). The incidence rates of postoperative complications such as neck flap sagging, adhesions, swallowing linkage, pain and numbness, and foreign body sensation were significantly lower in the observation group than those in the control group (all P<0.05). Follow-up was conducted for 6 to 24 months in both groups, and no cases of recurrence or metastasis were observed.Conclusion Gasless transaxillary endoscopic thyroid surgery demonstrates good efficacy and safety in middle-aged and elderly patients with thyroid cancer. It significantly reduces postoperative complications such as neck skin sagging, adhesions, swallowing linkage, pain and numbness, and foreign body sensation. Furthermore, it improves the quality of life for patients. Therefore, this surgical technique has certain clinical application value.