Key points: - The heterogeneity of retrosternal goiter size and location, nearby anatomical structures, and evolving surgical techniques means selecting the most appropriate individualised surgical approach remains challenging. - Although most retrosternal goiters can be removed transcervically, a small proportion of patients fulfill anatomical and radiological criteria for concurrent extracervical approaches based on decades of experience at the London Health Sciences Centre. - Anterior goiters above the level of the pericardium were resected using cervical thyroidectomy with either mediastinoscopic-assisted delivery or cervical thyroidectomy with video- assisted thyroidectomy (VATS) - Anterior goiters extending beyond the pericardium require median sternotomy to facilitate sufficient vascular control and exposure. - Posteriorly extending goiters can be managed using trans-thoracic approaches including lateral thoracotomy or VATS.