Objective <p>This study aims to comprehensively evaluate surgical efficiency and quality of life (QoL) differences among Conventional open thyroidectomy (COT), gasless endoscopic thyroidectomy trans-axillary approach (GETTA), transoral endoscopic thyroidectomy vestibular approach (TOETVA), and endoscopic thyroidectomy via bilateral-areolar approach (ETBAA) in T1 papillary thyroid carcinoma (T1-PTC) patients.</p> Study design <p>Prospective observational cohort study.</p> Setting <p>Tertiary academic center.</p> Methods <p>463 female patients with T1-PTC were stratified into four cohorts: GETTA (<i>n</i> = 122), TOETVA (<i>n</i> = 108), COT (<i>n</i> = 128), and ETBAA (<i>n</i> = 105). Perioperative time periods were divided into five parts for analysis. Level VI lymph node dissection was routinely performed, and the yield is reported. QoL was assessed using Voice Impairment Score (VIS), Swallowing Impairment Score (SIS), Scar Cosmesis Assessment and Rating (SCAR-Q), European Organization for Research and Treatment of Cancer QoL Questionnaire-Core 30 (EORTC QLQ-C30), and Symptom Checklist-90 (SCL-90). Longitudinal QoL trends were evaluated during postoperative recovery.</p> Results <p>Significant intergroup disparities were observed in surgical efficiency (<i>P</i> &lt; 0.001); COT demonstrated superior time efficiency. All cohorts experienced transient postoperative QoL declines, with endoscopic groups showing accelerated recovery trajectories in physical, psychological, and cosmetic domains (<i>P</i> &lt; 0.001).</p> Conclusion <p>Four techniques are safe and effective. COT remains the most time-efficient approach, while TOETVA excels in cosmesis. GETTA and ETBAA offer intermediate advantages, combining reasonable efficiency with enhanced recovery profiles. Clinical decision-making should prioritize patient-specific factors, including cosmetic preferences and recovery priorities.</p> Graphical abstract <p></p>