Indications for surgery for nodular goiter: 1. Nodular goiter with compression symptoms: the most common is tracheal compression causing bending, displacement and narrowing of the trachea, starting with shortness of breath and coughing only after activity, which may be aggravated by dyspnea even at rest, collapse of the trachea and cartilage degeneration. A small number of patients may have symptoms of compression of the esophagus, recurrent laryngeal nerve, sympathetic nerve, internal jugular vein and even the thoracic inlet. Patients with nodular goiter with peripheral organ compression, especially tracheal compression and deformation, should be treated surgically in a timely manner to avoid unnecessary emergency tracheal intubation or tracheotomy. 2. Post-thoracic goiter with compression symptoms or potential malignancy: Post-thoracic goiter is a goiter in which more than 50% of the volume is located below the entrance to the thorax. Since the left side of the post-thoracic sternum is blocked by the aortic arch and the left common carotid artery, post-thoracic goiter is more common on the right side of the clinic, and surgical treatment is the only effective method. It is generally divided into 3 types: type I is incomplete retrosternal goiter and type II is complete retrosternal goiter. Types I and II are due to the combined effect of the goiter’s own gravity, swallowing activity and negative pressure in the thoracic cavity, causing it to drop down into the thoracic cavity along the anterior tracheal space, and its blood supply still comes from the superior and inferior thyroid arteries; type III is rare and is an intrathoracic vagal goiter, and its blood supply is related to the intrathoracic vessels. Clinical practice shows that most type I and type II retrosternal goiters can be removed through a cervical surgical approach; very few type III can be removed through a sternotomy approach or a combined cervicothoracic approach. Preoperative examination, especially CT and MRI examination, can clearly show the location of the mass and its relationship with the large mediastinal vessels, so as to determine the choice of the surgical route; preoperative preparations for sternotomy must also be made. 3. Secondary hyperthyroidism: Simple goiter (5-8%) can be secondary to hyperthyroid symptoms, mostly manifesting as subclinical hyperthyroidism. It usually occurs in patients who have had nodular goiter for many years, and the symptoms of hyperthyroidism appear above the age of 40, with slow onset, mild disease, insignificant neuroexcitatory symptoms, rare protrusion of eyes, easy occurrence of myocardial damage, and may be accompanied by wasting and weakness. Surgical treatment should be performed in strict accordance with the preoperative preparation for hyperthyroidism, and total thyroidectomy or near-total thyroidectomy is the appropriate surgical method. Surgery has been gradually replaced by radioactive I131 therapy to reduce the risk of surgery and postoperative complications. 4. Nodular goiter with suspected malignancy: Patients with thyroid nodules should be highly suspected of thyroid cancer if they have the following conditions: ① family history of medullary thyroid cancer or multiple endocrine adenoma syndrome; ② rapid growth of the mass (especially during L-T4 treatment); ③ fixation of the mass; ④ fixation with surrounding tissues; ⑤ vocal cord paralysis; ⑥ enlargement of adjacent lymph nodes; ⑦ distant metastasis (lung or bone ). Moderate suspicion of thyroid cancer includes: ① age less than 20 years or more than 60 years; ② male; ③ isolated nodule; ④ history of head and neck radiation; ⑤ hard texture; ⑥ diameter greater than 4 cm and partially cystic; ⑦ pressure symptoms: dysphagia, dysphonia, hoarseness, dyspnea and cough. Whether nodular goiter is a precancerous lesion is inconclusive. The literature reports that serial thin sections in surgically resected nodular goiter specimens can reveal about 4-17% accompanied by thyroid cancer, and most of them are papillary carcinomas, and intraoperative freezing should pay attention to taking more material to avoid missing the diagnosis. In view of the fact that the detection rate of thyroid cancer in the normal population can be 10-30% at autopsy, its clinical significance needs to be further studied. 5. Nodular goiter affects appearance: superficially located nodular goiter may protrude from the anterior cervical region and affect appearance, and those located in the isthmus are obvious, and this group of patients is suitable for lumpectomy. The choice of surgical procedure for goiter: The choice of surgical procedure should be based on the number, size and distribution of nodules to select the appropriate surgical resection range. For single nodular goiter, mass removal, partial lobectomy or unilateral lobectomy is feasible; for multiple nodular goiters, if there are multiple nodules on one side of the lobe and smaller nodules on the opposite side, lobectomy + removal of nodules on the opposite side is feasible; if the nodules on the opposite side are small and cannot be detected during surgery, no surgery will be performed for the time being and follow-up will be performed. If there are multiple masses on both sides of the gland, if there are still some normal glands, lobectomy on one side + removal of most of the contralateral gland is feasible; 4. If there are multiple masses on both sides of the gland and there is basically no normal thyroid tissue, total thyroidectomy is performed. For patients with postoperative recurrence of nodular goiter who still require surgical treatment, the surgical route can be changed to a lateral approach, with access to the lateral thyroid region through the un-dissected sternocleidomastoid and strap muscles gap to minimize the probability of injury to the laryngeal recurrent nerve and parathyroid glands. For huge nodular goiters that do not want to undergo surgery or cannot tolerate surgery, radioactive I131 treatment is also an option to avoid serious surgical complications. In view of the fact that nodular goiter can be associated with adenoma, Hashimoto’s thyroiditis and thyroid cancer, and that there is a certain degree of complexity, a comprehensive and careful preoperative evaluation of patients should be performed to strictly grasp the indications for surgery and avoid unnecessary damage and waste of medical resources caused by overtreatment.