The papillary thyroid microcarcinoma (PTMC) is a subtype of the papillary thyroid carcinoma (PTC) 1 cm or less in diameter, bilateral and multifocal in a percentage of 15-20%. We describe our experience on the surgical treatment of 217 patient treated between 2005 and 2008. Our therapeutic algorithm for PTMC includes always total thyroidectomy with surgical exploration of the median cervical compartment and recurrent laryngeal nerve lymph node dissection, reserving the median lymph node dissection only to the cases with pathological lymph nodes and the lateral compartment lymphectomy to the cases that show suspect nodes with or without positive cytology. We usually perform total thyroidectomy rather than partial one, in relation to the high rate of multifocality of papillary microcarcinoma, to reduce rate of recurrencies and to better utilize I131 with diagnostic and curative aims. Complete central compartment dissection is mandatory when pathological nodes are present at surgical exploration. It prevents nodal recurrencies and decrease number of re-operations, that have a greater number of complications or morbidity, including hypoparathyroidism and inferior laryngeal nerve lesions. The rate of nodal metastases is not affected by the site of primitive tumor, but the tumor size does. The rate of nodal metastases varies from 55.7% for tumors 5 mm or less in diameter, to 73.7% for tumors sized from 5 to 10 mm, and is affected from the capsular infiltration, the presence of multiple foci, and the histological type, i.e. sclerosing type. All patients presenting papillary microcarcinoma with invasion of the capsule and extension to the perithyroid tissues, sclerosing histological type, multifocal and/or metastatic to the regional nodes, were treated with radiometabolic therapy and suppressing l-tiroxin administration, according to the guidelines of the Multidisciplinary Group for the Thyroid Cancer of our Institution.