**Background:** The United Italian Society of Endocrine Surgery (SIUEC) was established in 2017 from the merger of two pre-existing societies. Recognizing the need for updated, evidence-based protocols in thyroid surgery, a task force of 13 expert surgeons was commissioned to revise the 2016 position statement. The goal was to provide modern rational treatment protocols that account for new technologies, recent oncological concepts, and tailored approaches, while addressing clinical, healthcare, and therapeutic aspects, as well as potential sequelae and complications.
**Methods:** The task force reviewed the existing literature and international guidelines to formulate comprehensive recommendations across multiple domains: clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment (including minimally invasive and robotic techniques), non-surgical options (thermoablation, active surveillance), postoperative management, prevention and management of major complications, outpatient care, and follow-up. The document also describes the SIUEC accreditation system for thyroid centers, which requires at least two dedicated surgeons, routine application of international guidelines, a minimum of 50 thyroidectomies per year, 24-hour availability of anesthesia, intensive care, pathology, and imaging services, as well as access to endocrinology, otolaryngology, nuclear medicine, and vascular surgery. Centers performing ≥500 thyroidectomies per year are accredited as national thyroid referral centers.
**Key Results:** The guidelines provide specific recommendations for various clinical scenarios. For hyperthyroidism, total thyroidectomy is recommended over subtotal thyroidectomy due to a lower relapse rate (<5% vs. approximately 40% for anti-thyroid drugs and 21% for RAI). For benign nodular disease, lobectomy plus isthmectomy is recommended for unilateral disease, while total thyroidectomy is recommended for multinodular goiter. For differentiated thyroid carcinoma (DTC), total thyroidectomy remains the standard for most cases, but hemithyroidectomy may be considered for intrathyroidal tumors <2 cm without other risk factors. Active surveillance is an option for low-risk microcarcinoma. For medullary thyroid carcinoma (MTC), total thyroidectomy plus central node dissection is strongly recommended regardless of calcitonin levels. For anaplastic carcinoma, multimodal treatment is emphasized, with surgical resection with curative intent offered only if complete resection (R0/R1) can be achieved with minimal morbidity. The guidelines also detail indications for thermoablative treatments: radiofrequency ablation (RFA) and laser ablation (LA) are recommended for symptomatic benign nodules ≥30 mm or ≥6 ml, hyperfunctioning nodules <10 ml, and selected microcarcinomas or lymph node recurrences in patients who refuse surgery or are high-risk. Prophylactic central lymph node dissection (PCLND) in clinically node-negative PTC is not routinely indicated but may be considered for advanced tumors (T3/T4), bilateral/multifocal tumors, or known lateral neck disease. Therapeutic lateral neck dissection (levels IIA, III, IV, V) is recommended for biopsy-proven lateral metastases. The incidence of post-thyroidectomy hemorrhage is 0.1–2%, with most cases occurring within 6 hours. Transient hypoparathyroidism occurs in 19–39% of patients, permanent in 0–15%. Transient recurrent laryngeal nerve (RLN) palsy occurs in approximately 3–12% of cases; permanent rates are not clearly reported. Bilateral RLN palsy may require tracheostomy in about 30% of cases. Intraoperative nerve monitoring (IONM) is recommended to reduce the risk of bilateral vocal cord palsy, and if loss of signal occurs after the first lobectomy, a two-stage thyroidectomy should be considered.
**Clinical Implications:** These guidelines provide a comprehensive, evidence-based framework for the management of surgical thyroid diseases, emphasizing individualized, risk-stratified approaches. The recommendations aim to standardize care across Italian endocrine surgery centers, improve patient outcomes by reducing complications (e.g., hypoparathyroidism, RLN injury), and optimize the use of new technologies such as IONM, minimally invasive techniques, and thermoablation. The emphasis on multidisciplinary management and dynamic risk assessment during follow-up is expected to enhance the quality of care for patients with thyroid cancer. The SIUEC accreditation system also promotes quality assurance by setting minimum volume and resource requirements for thyroid centers.