AIM OF THE STUDY: The Authors report on their experience in the surgical treatment of substernal goiter. MATERIAL AND METHODS: Between 1972 and 2004, 222 patients with substernal goiters were observed among 2720 patients undergoing surgical treatment for various thyroid diseases (8.16%). Seventy patients underwent subtotal thyroidectomy and 152 total thyroidectomy. A cervical approach was employed in 213 cases, a sternotomy was required in 7 patients while a thoracotomy was necessary in 2 cases. Postoperative complications were definitive hypoparathyroidism in 9 cases (4%), recurrent laryngeal nerve palsy in 5 patients (2.2%) and postoperative bleeding in 4 cases (1.8%); there was no intraoperative mortality. CONCLUSIONS: In substernal goiter it is necessary to define its exact relationship to neck and mediastinal structures in order to establish the most appropriate surgical approach. In the majority of the cases total thyroidectomy is possible through a cervical approach with an acceptable morbidity rate. When dissection of the substernal goiter is difficult and recurrent laryngeal nerve is not clearly identified, partial sternotomy is required to enable a better control of the nerve and the vessels with only a minimal morbidity rate. Thoracotomy is rarely necessary.