T hyroid surgery has always been associated with a high risk of bleeding since its birth: " […] there is a grave risk of death from hemorrhage during thyroid operations and it is a procedure by no means to be thought of […]" (Robert Liston (1794-1847, "[…] thyroidectomy is one of the most thankless, and most perilous undertakings […]" (Dieffenbach Johann Friedrich (1792-1847, "[…] no sensible man will […] attempt to extirpate a goiter of the thyroid gland […] every step he takes will be environed with difficulty and every stroke of his knife followed by a torrent of blood and lucky will it be for him if his victims live long enough to enable him to finish his horrid butchery […]" (Samuel D. Gross, 1805 -1884.Blood flow through the thyroid gland is high (Table 1). Haemorrhage in general surgery can be classified into three main categories: (a) primary bleeding, i.e., bleeding that occurs within the intra-operative period. [1] This should be resolved during the operation, with any major haem-orrhages recorded in the operative notes, and the patient monitored closely postoperatively. (b) Reactive bleeding i.e., occurs within 24 hours of operation. Most cases of reactive haemorrhage are from a ligature that slips off or an unacknowledged vessel. [2] Often, these vessels are not recognized intraoperatively due to intraoperative hypotension and vasoconstriction; once the blood pressure falls back into a normal range postoperatively, the unacknowledged vessel will then start bleeding. [3] (c) Secondary bleeding i.e., occurs 7-10 days postoperatively. Secondary haemorrhage is often due to the erosion of a vessel from a spreading infection. [4] Secondary haemorrhage is most often seen when a heavily contaminated wound is closed primarily. The fo-Prospective studies on the incidence, etiology, and prognosis of well-characterized patients with bleeding after thyroid surgery are lacking. Bleeding after thyroid surgery cannot be predicted or prevented even if risk factors are known in every single procedure, which enhances the im-portance of the following issues: (a) meticulous hemostasis and surgical technique; (b) coopera-tion with the anesthesiologist, i.e., controlling the Valsalva maneuver, adequate blood pressure at the end of the operation as well as at extubation phase and (c) in case of bleeding, a prompt management to guarantee a better outcome. This requires an intensive postoperative clinical monitoring of patients, ideally, in a recovery room with trained staff for at least 4-6 h. Early recognition of postoperative bleeding with immediate intervention is the key to the management of this complication.

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