Abstract Background: The definition of retrosternal goiter (RSG) is not uniform and varies among authors, some authors de-scribed retrosternal goiter as one that extends down to the aortic arch. Others defined retrosternal goiter as a lesion of the thyroid extending to the fourth thoracic vertebrae on chest X-ray. Aim of Study: Perform a systematic review/meta-analysis to identify and assess factors that affect decision making in huge retrosternal goiter, whether sternotomy might be or might not be needed. And to assess the different tools used in decision making. Material and Methods: This systematic review was con-ducted following the Cochrane Handbook for Systematic Reviews of Interventions. We also adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines during the design of our study. We conducted a literature search using PubMed, Scopus, Web of Science, and Cochrane Library. Clinical studies were conducted from January 2000 till August 2022 using MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials (CEN-TRAL), Clinical Trials.gov., EMBASE, Web of Science, SCOPUS, and Grey Literature Searching, and journals related to the topic by using these keywords: huge goiter, retrosternal, total thyroidectomy, sternotomy, and cervicothoracic approach. Results: We reported a total of 32 complications in cervical approach in form of tracheomalacia, hemorrhage, visceral injury, fistula, pneumothorax/pneumonia, Wound problems, and 9 complications in steronotomy in form of pleural effusion, hemorrhage, pneumothorax/pneumonia, tracheomalacia, wound problems. Three studies showed tracheal deviation/compression found significant higher among steronotomy procedure vs cervical. Pneumothorax/pneumonia and tracheomalacia were found insignificant differences between steronotomy procedure and cervical. Conclusion: The cervical approach for patients with RSG extending to the aortic arch is an optimum, feasible and less invasive surgical approach that can considered the appropriate choice in such cases and can be performed successfully by experienced specialized surgeons. Thoracic surgeon standby is required in a few selected cases which carry a chance that sternotomy might be needed.