The thyroid gland is a butterfly-shaped gland located in the lower part of the anterior surface of the neck between the fifth cervical and the first thoracic vertebra. Usually, it consists of two lateral, almost symmetrical lobes, the connective isthmus and the pyramidal lobe. The pyramidal lobe is a conical or cylindrical projection of the gland's parenchyma that extends superiorly to the thyroid cartilage or the hyoid bone. Most often, it originates from the isthmus and it is located to the left of the middle line. It can be absent in up to 50% of the cases. From the time of Theodor Kocher who performed the first classic thyroidectomies, we are now entering the era of minimal access thyroid surgery where new techniques are devised in order to provide a better cosmetic result. The presence of the pyramidal lobe is a classic example of an anatomic variation of the thyroid gland that plays an important role in the completeness of a total thyroidectomy, especially when the procedure is carried out for an autoimmune or malignant disease. The pyramidal lobe can also increase the complexity of minimal access procedures that are nowadays applied for the removal of the thyroid gland. The purpose of this article is to outline the importance of the pyramidal lobe in minimal access thyroid surgery.