The goal of surgical treatment of hyperthyroidism is to restore normal thyroid function by removing a sufficient amount of thyroid tissue. The key to perioperative management is to normalize thyroid function as much as possible before surgery to reduce the risk of surgical treatment. Comprehensive perioperative treatment includes inhibition of thyroid hormone (TH) synthesis and release, inhibition of TH conversion in peripheral tissues, correction of compensatory dysfunctions of various body systems, and restoration of homeostasis. Preoperative hyperthyroidism (hyperthyroidism), whether performed as thyroid surgery or non-thyroid surgery, increases the risk of surgery and requires active intervention. The patient’s own wishes are also an important consideration in choosing different treatment options. In addition, a small number of patients with hyperthyroidism require non-thyroidal surgery due to surgical emergencies. The key to perioperative management is to normalize thyroid function clinically and biologically as much as possible before surgery in order to reduce the risk of surgical treatment. Preoperative management: To reduce the risk of thyroidectomy in hyperthyroid patients, the goal of preoperative management is first to normalize thyroid function and second to reduce surgical bleeding by shrinking and stiffening the enlarged thyroid tissue. The preoperative drug regimen usually depends on the etiology and severity of the patient’s thyrotoxicosis. A combination of ATD and beta-blockers is usually required to restore thyroid function and basal metabolic rate as soon as possible, and 10 days of iodine therapy is required prior to surgery to reduce blood flow to the thyroid tissue, decrease TH release from the gland, and inhibit the conversion of peripheral T4 to T3. It is important not to schedule surgery and start iodine therapy before thyroid function reaches normal or the upper limit of normal, and not to discontinue ATD after starting iodine therapy; the main indicators of thyroid function in the preoperative phase are FT3, FT4, and TT3 and TT4; TSH below normal is not a contraindication to surgery because TSH secretion is often suppressed for a long time. Traditional preoperative preparation for thyroidectomy includes the application of ATD and preoperative treatment with Lugol’s solution for 10 days (up to 2 weeks). Since most patients undergoing surgery are severely hyperthyroid or have significant goiter, relatively high oral doses of thioureas (propylthiouracil 200 mg three times daily) or imidazoles (methimazole 15-20 mg twice daily) are recommended to rapidly inhibit TH synthesis and deplete TH stores in the thyroid gland until normal metabolic status is restored and thyroid function The thyroid function reaches normal or upper limit of normal. Methimazole has a longer half-life and higher potency, and granulocyte deficiency rarely occurs at doses below 40 mg daily, whereas propylthiouracil (PTU) inhibits the conversion of T4 to T3 in peripheral tissues at doses of 600 mg daily or more, facilitating a more rapid reduction in blood T3 levels. After thyroid function reaches normal or the upper limit of normal, 5 drops of compounded iodine solution 3 times a day or 1-2 drops of saturated potassium iodide solution (SSKI) 3 times a day should be started on top of continued ATD for 10 days until preoperative. Some people also use ATD in combination with TH, when levothyroxine is started 2 weeks before surgery at 100 μg daily until preoperative. ATD combined with iodine for preoperative preparation often takes at least several weeks or even months to bring the patient’s thyroid function to normal. The combined use of β-blockers can lower the basal metabolic rate and control the symptoms of hyperthyroidism, especially tachycardia, arrhythmias and other symptoms of the cardiovascular system, and can be used for preoperative preparation, and propranolol alone has been reported in the past for rapid preoperative preparation. Propranolol can inhibit the conversion of T4 to T3 in peripheral tissues, while the longer-acting β-blockers atenolol and short-acting esmolol and metoprolol do not inhibit the conversion of T4 to T3, therefore, propranolol is still the most widely used β-blocker. The dose of propranolol should be determined according to the severity of the patient’s condition and response to treatment. Due to the accelerated metabolic clearance of β-blockers in hyperthyroidism, a larger dose is required, generally 10-60 mg of propranolol, administered orally every 6-8 hours. If there are contraindications to propranolol such as bronchial asthma and chronic obstructive pulmonary disease, selective β1-blockers should be used. For those who cannot take it orally or for those with severe hyperthyroidism or poorly controlled arrhythmias such as atrial fibrillation, rapid-acting agents such as metoprolol or esmolol can be used for IV therapy. This class of drugs should be contraindicated in cases of atrioventricular block and congestive heart failure of degree II or higher. In severe hyperthyroidism, oral radioactive iodine contrast agents (IRCAs) such as iopanoic acid, combined with ATD, glucocorticoids and β-blockers have been reported to rapidly control thyrotoxicosis. IRCAs not only inhibit the release of thyroid hormones from the gland, but also competitively inhibit type I and II 5’deiodinase, which inhibits the conversion of T4 to T3 in the liver, brain tissue, and thyroid, resulting in a rapid decrease in T3 levels. In the preoperative management of severe hyperthyroidism, iopanic acid, dexamethasone, β-blockers and sometimes ATD were administered simultaneously, which rapidly controlled thyroid function. This group of patients underwent total or subtotal thyroidectomy 7 days after treatment and did not experience postoperative thyroid crisis, permanent parathyroidism, vocal cord paralysis, or worsening ophthalmoplegia. Of course, IRCAs cannot be used in patients with Graves’ disease who are undergoing non-surgical treatment. Subclinical hyperthyroidism is usually treated with iodine for only 7-10 days before thyroidectomy. Preoperative preparation for non-thyroidal surgery in patients with hyperthyroidism is determined by the severity of the primary surgical disease. For elective surgery, a combination of ATD and β-blockers may be used. Since non-thyroidal surgery is not performed, iodine is not used for preparation, but anesthesia and surgery must be performed only after normal thyroid function is achieved. In case of surgical emergencies before treatment or control of hyperthyroidism, the condition can be worsened by combined rapid preparation similar to that for hyperthyroidism crisis. (2) PTU 200mg or methimazole 20mg every 4h orally, or intrarectally if it cannot be given orally; (3) Iopanoic acid 500mg twice daily orally; (4) Hydrocortisone 100mg every 8h or dexamethasone 2mg every 6h orally or intravenously, as mentioned above, the above method can make the thyroid function close to normal within a few days. Intraoperative management: The aim of surgical treatment of hyperthyroidism is to restore normal thyroid function by removing sufficient thyroid tissue, while avoiding or minimizing the chance of surgery-induced damage to the recurrent laryngeal nerve and hypoparathyroidism. The conventional wisdom advocates performing bilateral subtotal thyroidectomy, but the amount of thyroid tissue to be preserved remains controversial, with most advocating 5 g of tissue on each side and 2-4 g for children, who are more prone to recurrent hyperthyroidism than adults. Further studies have found that the more thyroid tissue removed the better the control of hyperthyroidism, but the higher the incidence of hypothyroidism. Some surgeons recommend near-total or even total thyroidectomy because the chance of postoperative complications such as worsening ophthalmopathy, residual tissue malignancy, and recurrence of hyperthyroidism is lower than with subtotal resection, and total thyroidectomy is safer for combined multiple nodules. Of course, total thyroidectomy requires patients to take thyroxine for the rest of their lives after surgery, while subtotal thyroidectomy has a certain recurrence rate of hyperthyroidism. In order to reduce the incidence of postoperative hypothyroidism, we advocate that subtotal resection should be preferred for Graves’ disease. In case of recurrence of hyperthyroidism, isotope iodine therapy is preferred because the risk of complications is significantly higher when reoperation is performed. Hyperthyroidism combined with surgical emergencies is often not adequately controlled by rapid preoperative preparation. Intraoperative short-acting β-blockers such as landiolol must still be used intravenously and the heart rate should be kept within 90 beats/min. Postoperative management: Postoperative management generally varies depending on the etiology, severity, preoperative control status and surgical approach of hyperthyroidism. Since the half-life of T4 in the blood circulation is 7-8 days, thyrotoxicosis that is not adequately controlled before surgery usually does not resolve immediately after thyroidectomy, so preoperative treatment should not be terminated immediately after surgery, but should be gradually reduced and discontinued after several days, except for iodine or IRCAs, which should be discontinued immediately after surgery. Because ATD acts mainly on the thyroid gland, it should be discontinued immediately after total thyroidectomy. In patients who have achieved normal thyroid function preoperatively, the beta-blocker dose can be gradually reduced over 2 weeks until it is discontinued postoperatively. In patients with hyperthyroidism undergoing non-thyroidal surgery, preoperative management must be continued, and because there is no extra-digestive route of administration of ATD, endorectal administration should be performed until recovery from oral ATD therapy. Glucocorticoids should be gradually discontinued within 72h postoperatively. Thyroid crisis mostly occurs in patients with inadequate preoperative preparation and inadequately controlled hyperthyroid symptoms. The occurrence of crisis may be related to a weakened stress response of the pituitary-adrenocortical axis. Routine use of dexamethasone 10mg-20mg/d intravenously for 2-3 days in postoperative patients is an effective way to prevent the occurrence of thyroid crisis. In conclusion, all phases of perioperative management of hyperthyroidism are important. Normal thyroid function must be restored before surgery to avoid or minimize the risk of hyperthyroid crisis and other surgical treatments. Comprehensive therapeutic measures should be taken in the management, including inhibition of TH synthesis and release, inhibition of TH conversion in peripheral tissues, correction of compensatory dysfunctions of various body systems, and restoration of homeostasis, among many other aspects. Pre-operative rapid preparation for hyperthyroidism combined with surgical emergencies is required, as well as the use of short-acting β-blockers during surgery, and post-operative treatment of hyperthyroidism should not be relaxed. In addition, supportive therapy and protection of vital organ function are essential for the perioperative management of hyperthyroidism.