Introduction and importance This case series describe the efficacy of hemi-thyroidectomy to relieve the compressive symptoms of cases having large multi-nodular goiter with preservation of the thyroid gland function. It's considered as an education tool for surgeons to perform safe hemi thyroidectomy to patients indicated for total removal of the gland. Compressive symptoms like mild/severe dysphagia or dyspnea associated with both benign and malignant thyroid disease. Although total thyroidectomy is currently considered the standard of care, hemi thyroidectomy is another surgical option with more benefits. Case presentation This case series was performed in a tertiary university hospital in Riyadh, Saudi Arabia. It included 35 females and 3 males above the age of 18 (mean age 42 years). All the operations were elective hemi-thyroidectomies performed by one surgeon, during 2019. Patients were complaining of; Voice Change, Neck Swelling, Dysphagia, Chocking, SOB, and Orthopnea. 20 of them were medically free and 18 patients had multiple associated comorbidities. Clinical findings and investigations Demographic data, baseline co-morbidities, TSH levels prior to surgery, thyroid gland size, FNA results and pre-operative symptoms were recorded. In addition, compressive symptomatology outcomes from two weeks to two years were recorded. Thirty-two of them (84%) had their symptoms resolve completely and did not need a completion surgery. Out of the 6 who had persistent symptoms, only two needed a completion surgery. Furthermore, only 34.2% required thyroid hormone replacement, 31.6% were euthyroid and 2.6% were hypothyroid preoperatively. Interventions and outcome Hemi thyroidectomy was chosen to avoid the risk of hormone replacement, and hypocalcemia. Our results revealed that compressive symptoms were effectively relieved in the majority of our patients. Only 2 patients had to undergo completion thyroidectomy due to compressive symptoms with no perioperative or postoperative complications. Relevance and impact We would recommend hemi thyroidectomy for cases of large multi nodular goiter due to its positive implication on patient outcome particularly if the patient refuse hormonal replacement.