Objective To investigate the efficacy and complications of endoscopic surgery through three different approaches in the treatment of thyroid microcarcinoma. Methods We retrospectively included 240 patients with thyroid microcarcinoma who had undergone endoscopic surgery in The Second Affiliated Hospital of Wannan Medical College from January 2020 to March 2023. According to surgical approaches，the patients were divided into transoral vestibular approach group（n=71），transaxillary approach group（n=73）， and breast approach group（n=96）. The three groups were comparted in terms of general clinical data， perioperative indicators，postoperative pain，incision aesthetics，patients’ degree of satisfaction， and postoperative complications. Results The operation time of the transaxillary group was significantly shorter than that of the other two groups（P<0.001）. The length of incision was significantly different between the three groups： the transoral group < the breast group < the transaxillary group（P<0.001）. The transoral group had a significantly greater number of dissected central lymph nodes and a significantly shorter dissection time compared with the other two groups（P<0.001）. The visual analogue scale score was significantly lower in the transoral and transaxillary groups than in the breast group at 6 h，12 h，24 h，and 48 h after operation（P<0.001）. The transoral group and the transaxillary group were significantly superior to the breast group in incision aesthetics and patients’ degree of satisfaction（P<0.001）. The overall incidence of complications showed no significant difference between the three groups（P=0.491）. Conclusion Endoscopic surgery through the three approaches were equivalently effective in the treatment of thyroid microcarcinoma， with no difference in complications. However，the transaxillary approach showed the shortest operation time， and the transoral vestibular approach was superior in central lymph node dissection， dissection time， and incision aesthetics while ensuring the effectiveness. Surgical approach selection should be based on patient’s actual condition.