Video-assisted thyroidectomy (VAT)has become a valid option for the treatment of small thyroid nodules. One theoretical limit of VAT was the necessity of general anaesthesia. After acquiring a large experience, we approached VAT under local anaesthesia (VAT-LA). VAT-LA is performed under a superficial cervical block (mixture of Bupivacaine 0.25% and Carbocaine 0.5%) and intravenous sedation with Midazolam and Remifentanyl. During the procedure the patient is awake. VAT is performed as usually. Eligibility criteria are:small thyroid nodules (< 2 cm) in small or normal thyroid gland (volume 20 ml), no previous neck surgery or irradiation, patients motivation. Fourteen VAT-LA were attempted: 5 lobectomies and 9 total thyroidectomies. In three cases total thyroidectomy was performed in women during the second trimester of pregnancy, because of the diagnosis of papillary carcinoma. No conversion was necessary. Mean operative time was 45 minutes for thyroid lobectomies and 63 minutes for total thyroidectomies. Postoperative and intraoperative pain was negligible. No complication occurred. Mean postoperative stay was 26 hours. Final histology was papillary carcinoma in 9 patients and follicular adenoma in four. All the patients were satisfied with the cosmetic result and the procedure. VAT is feasible and safe also under local anaesthesia. We are optimistic about the future of this approach that really opens a new frontier in the minimally invasive procedures for thyroid surgery.