Objective To compare the therapeutic effects of endoscopic and open surgical treatments for patients with thyroid microcarcinoma. Methods A total of 82 patients who underwent thyroid microcarcinoma surgery from January 2022 to June 2024 were selected and randomly divided into two groups by random number table method. The control group （41 cases） received open surgery treatment, while the observation group （41 cases） underwent thyroid surgery through the transthoracic approach using laparoscopic techniques. The surgical indicators （operative time, intraoperative blood loss, and number of central lymph nodes dissection）, treatment effects, and safety between the two groups were compared. Results The operative time and number of central lymph nodes dissection of the observation group were higher than those of the control group, while the intraoperative blood loss was less （P<0.05）. There was no statistically significant difference in immune function indicators （CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺） between the two groups before treatment （P>0.05）. However, after treatment, the CD8⁺ was lower and the other immune function indicators were higher in the observation group than those in the control group （P<0.05）. The scores of Patient and Observer Scar Assessment Scale （POSAS） and Observer Scar Assessment Scale （OSAS） in the observation group were higher than those in the control group after treatment （P<0.05）. Additionally, the incidence of postoperative complications in the observation group was lower than that in the control group （P<0.05）. Conclusion Compared with open surgery, transthoracic endoscopic thyroid surgery for patients with thyroid microcarcinoma could improve surgical indicators and immune function, alleviate pain, optimize scar scores, and reduce the occurrence of complications. This approach merits further clinical promotion.