Removing a giant goiter like this one, which is common in Nigeria, is a formidable task. They have large blood vessels that are very friable. Often the bleeding doesnt stop completely until the goiter is completely out. In addition to removing the goiter safely, we need to do it expeditiously-on mission trips, there are a lot of patients waiting. We have developed some tricks to do it.

First, we get the goiter out of the neck and mediastinum-rather than working on the goiter in the neck. The relatively small skin incision, compared to the size of the goiter,  tends to constrict the base where the vessels are coming from. Second, we work fast. We only ligate the "staying side of blood vessels" while the assistant applies pressure to the "specimen side of blood vessels". We also use a clip applier when available. These clip appliers, made by AutoSuture or Ethicon, really help things move along. Third, if bleeding becomes heavy in one place, we apply pressure and work somewhere else. Fourth, we identify parathyroid glands and the recurrent laryngeal nerves early and protect them. 

The above are basic principles-nothing really new. We usually complete a total thyroidectomy in about one hour. A bunch of these goiters are waiting for us  for our May trip.