The normal thyroid gland is located in the anterior cervical region, on either side of the trachea, and therefore the area where most thyroid surgery is performed is in the neck. However, there are some special thyroids that can even directly affect numerous blood vessels and nerves in the neck due to their anatomical location variants, which can be extremely challenging for the surgeon’s surgical skills. Here we will share a rare surgical procedure of a giant retrosternal goiter compressing the trachea, pushing the esophagus, and invading the recurrent laryngeal nerve. The patient was a male, 46 years old. Bilateral thyroid nodules were detected by ultrasound at a local hospital two years ago, but were not taken seriously at that time. One year ago, he gradually developed a sensation of foreign body and obstruction during swallowing, and due to the progressive aggravation of his condition, he consulted the local hospital for the foreign body sensation. The main surgical risks for the patient are as follows: 1. A retrosternal goiter is a simple enlargement of the thyroid gland or a thyroid tumor located behind the sternum or within the mediastinum. In general, a posterior sternal goiter is defined when 50% of the thyroid gland is located in the posterior sternal space. In this patient, based on imaging evaluation, 80% of the thyroid tissue was found to be located in the retrosternal space, and the inferior thyroid pole was immediately adjacent to the arch of the thoracic aorta, the largest vessel emanating from the heart, and its three major branches. If the large vessels were torn during surgical dissection, the patient could have died on the spot. 2. In most cases of retrosternal goiter, the surgery can be completed in the neck through a cervical incision by freeing the gland and dragging out the thyroid gland that extends into the chest cavity. However, 80% of the thyroid gland in this patient was located in the thoracic cavity and the 20% of the gland in the neck could not provide a point of contact, making it difficult to tractor 80% of the gland to the neck. In addition, 80% of the gland is free through the neck, which makes it very difficult to expose the field of view, and the operating space is extremely narrow, even to the point of “canal effect”, which makes it very difficult to perform surgical operations such as suturing and hemostasis, which are originally very easy. In addition to the neck incision, the sternal body must be split and the mediastinal pleura must be incised to fully expose the surgical field and complete the surgery. However, the thoracic approach is very traumatic and can not only damage the surrounding blood vessels, nerves, trachea and esophagus, but also affect the lung function of the patient. 3. The recurrent laryngeal nerve is an important nerve that innervates the vocal cords and is one of the most important cervical nerves of concern in thyroid surgery. The right recurrent laryngeal nerve is divided from the vagus nerve stem at the level of the right subclavian artery and travels obliquely to the neck, then up the tracheoesophageal groove and gradually into the larynx, while the left recurrent laryngeal nerve is divided from the vagus nerve stem at the level of the aortic arch and travels up the tracheoesophageal groove to the back of the neck. Although the course of the left and right recurrent laryngeal nerves was not the same, both were dorsal to the thyroid gland and ascending along the paratracheoesophageal groove. Preoperative CT revealed that this patient’s retrosternal goiter originated from the right thyroid gland, and the enlarged gland extended into the chest cavity precisely along the tracheoesophageal sulcus posterior to the trachea, and the gland must have been close to the recurrent laryngeal nerve. At the same time, due to the limitation of the operating space and visual field exposure of the cervical incision, it was impossible to completely dissect the recurrent laryngeal nerve intraoperatively. 4. The retrosternal goiter in this patient originated from the right thyroid gland, but due to the huge gland, it severely pushed and compressed the trachea and esophagus to the left, and even some of the gland extended surprisingly to the posterior esophagus. In clinical practice, it is not uncommon to see accidental damage to the esophagus due to thyroid surgery. In this patient, part of the gland was located posterior to the esophagus, so during resection, the esophagus also had to be freed, and if the surgery was performed in the neck, the operating space was extremely narrow and the field of view was obviously restricted. 5. Since the huge post-thoracic goiter obviously compresses the surrounding tissues, the important organs such as the parathyroid glands deviate from their normal anatomical position, especially the parathyroid glands in the right lower pole, which may not be identified under direct vision and may be easily damaged during surgery, resulting in serious complications. 6. Due to the long-term compression of the huge retrosternal goiter, which leads to softening of the tracheal cartilage, once the thyroid gland is removed, the tracheal cartilage is likely to collapse when the trachea loses the support of the thyroid gland, leading to postoperative asphyxia and the need for tracheotomy. After the patient was admitted to the hospital, experts from the Department of Anesthesiology, Department of Thoracic Surgery, Department of Critical Care Medicine and other related departments were consulted. The chief of the Department of Thoracic Surgery thought that a huge retrosternal goiter, which extended 80% into the chest cavity, would be very difficult to operate on through the neck and was almost an “impossible task”. However, after communicating with the family several times, it was decided to challenge the risk and complete this case through a cervical incision to remove the giant retrosternal goiter. In July 2015, a giant retrosternal goiter was resected by the chief surgeon at the General Hospital. During intraoperative investigation, the right thyroid gland extended along the right tracheoesophageal groove toward the thoracic cavity and densely adhered to the surrounding tissues, making it impossible to expose and protect the right recurrent laryngeal nerve throughout. Part of the right inferior pole of the thyroid gland moved down along the posterior tracheoesophageal groove to the anterior superior mediastinum behind the sternum and was close to the right pleural roof, and the trachea was obviously pushed to the left side, and part of the gland extended to the posterior esophagus, making it impossible to expose and protect the esophagus. Intraoperatively, we talked with the family again and informed them that the right laryngeal recurrent nerve could not be preserved and that hoarseness might occur after surgery, while the cooperation and understanding of the family was an important factor for the success of the operation. Through the cervical incision, the difficulties of visual field exposure and small operating space were overcome, the trachea and esophagus were completely freed, and the right inferior parathyroid gland was completely stripped and protected with great patience, and finally the right thyroid gland and all of the retrosternal thyroid gland were successfully and radically removed. After complete removal of the tumor, the surgery did not end there. To maximize the patient’s quality of life, the director fully freed the two severed ends of the right recurrent laryngeal nerve and reconstructed the right recurrent laryngeal nerve with a microsurgical technique using a 6-0 Prolene polypropylene surgical suture with a diameter of only 20 microns (um), which is thinner than half a hair (average diameter The 6-0 Prolene suture is thinner than half a hair (average diameter 50 um), so the reconstruction of the nerve requires great patience and solid microsurgical skills. The patient recovered well after the operation without any complications, and due to the repair and reconstruction of the recurrent laryngeal nerve during the operation, the patient’s voice was not significantly hoarse after the operation, and he was discharged 2 days after the operation. The difficulty of this case was that such a huge retrosternal goiter compressed the nerve, trachea and esophagus, and the lower end invaded the arch of the thoracic aorta and the tip of the lung, which could cause irreparable damage if the operation was not done carefully. The patient’s outcome was finally achieved through careful reading of the imaging data and the development of an individualized surgical plan, combined with perfect perioperative management, delicate surgical operation and excellent postoperative care.