Background and Aims: How to effectively expose and protect the recurrent laryngeal nerve (RLN) during endoscopic thyroid surgery, has always been a difficult and unavoidable part of this procedure. The conventional approaches to the RLN are usually divided into lateral, inferior, and superior approaches. Here, the authors introduce a medial approach to RLN during endoscopic thyroidectomy, and summarize its effects, so as to provide reference for surgeons in the same field. 
Methods: The clinical and video data of 83 patients with papillary thyroid carcinoma undergoing endoscopic total thyroid lobectomy via the trans-thoracoareolar approach from January 2019 to November 2020 were retrospectively analyzed. Medial approach to the RLN was adopted in all patients during operation, namely, firstly to separate the loose parts of the ligament of Berry up to the tracheothyroid groove, to find the main trunk of the RLN and secondly, along the superficial surface of the RLN toward the superior direction, to cut the compact parts of the ligament of Berry from superficial to deep, to fully expose the main trunk of the RLN and the insertion point of the RLN into the larynx. The RLN exposure effect and the postoperative recovery of the patients were observed.
Results: The endoscopic procedures were successfully completed in all the 83 patients. A total of 130 RLNs were exposed, and the exposure rate was 100%, with complete exposure of the main trunk of the RLN and the insertion point of the RLN into the larynx in all cases. The time for unilateral RLN exposure was 4.2–15.6 min, with an average of 8.9 min. The intraoperative blood loss was 2–15 mL, with an average of 5.3 mL. After operation, transient RLN injury occurred in 3 patients (0.36%), and no permanent RLN injury was found in all patients.
Conclusion: In endoscopic thyroid surgery, using the medial approach can safely, efficiently and easily expose the whole course of the RLN, and reduce the incidence rates of RLN injuries. So, this approach is recommended to be used in clinical practice.