Alvarado et al. [1], Miccoli et al. [2], Slotema et al. [3], and Tan et al. [4] have reported comprehensive reviews of endoscopic thyroidectomy in which they critically overhauled all papers written on this topic. Major improvements and safer technologies have been proposed and applied to thyroid surgery in recent years. For example, intraoperative neuromonitoring to prevent laryngeal nerve paralysis [5], early measurement of iPTH to avert symptomatic hypocalcemia [6], modern devices for hemostasis, and dissection to better control bleeding [7]. Furthermore, genetic screening with improvement of survival rate [8]. The impact of these technologies on quality of thyroid surgery is remarkable [9]. Likewise minimally invasive thyroid procedures gradually lead to a surgical progress improving the perioperative and postoperative quality of life: extracervical access achieved excellent result for cosmesis; minimally and video-assisted techniques ameliorated the postoperative course. By definition, these are real progresses in surgery. At present there are no large, prospective, randomized trials with clear-cut results, low risk of errors, provided sample size calculation, and end points. Studies that compare outcomes of different minimally invasive thyroidectomy with outcomes of conventional surgery are desirable and can yield a conclusive answer whether endoscopy reduces or maintains the results of standard thyroidectomy. Certainly, research with high level of evidence (I) and grade of recommendation (A) is difficult to develop [10, 11]. The reason is that most thyroidectomies are still performed for large goiters and advanced cancers [1]. In fact, minimally invasive thyroid procedures are mainly for diagnostic surgery for undetermined nodules in small goiters and follicular tumors [1–4, 12]. According to different authors, between 5% and 10% of all patients will undergo an endoscopic thyroidectomy (i.e., approximately 30 cases/year in a high-volume center) [1–4, 12]. Moreover, there are many preoperative and postoperative variables to be considered, such as patient selection criteria, type of access and incision length, completeness of the procedure, gland volume, and technology consumed. The varying surgical experience also is a factor. Thus, to show a reduction in the rate of morbidity from endoscopic thyroidectomy vs. conventional thyroidectomy from 2% to 1%, single surgeon, a study group of approximately 1000 patient/arm would be necessary (a = 0.05, power = 0.8, one-tailed t test) to claim reasonable statistical power [13]. To date such a study is hard to establish in a prospective manner. Current and future trends in research will focus on developing dedicated surgical instruments [1] and optimizing patient selection criteria. Considering that the prevalence of thyroid disease is much higher in young women than men, scarless endoscopic thyroidectomy would be highly beneficial for these patients. New devices will tend to a less invasive procedure and will probably enlarge patient selection criteria with more advanced neck endoscopic procedures [14–16].