Parathyroid Parathyroid Surgery

There are two main approaches to parathyroid surgery which can be accomplished using local anesthesia and small incisions (minimally invasive surgery) with the possibility for same day discharge after a period of observation (6 hours).

Traditional

This is the standard approach to parathyroid surgery which has been used for the treatment of parathyroid disorders and involves a bilateral (both sides of the neck) exploration for the removal of diseased parathyroid glands. In the past, patients offered this approach were typically given a general anesthetic. Today, we have developed a minimally invasive approach using small incisions and local anesthesia. Bilateral surgery is most often required for patients suspected of having multiglandular parathyroid disease, those who have co-existing thyroid nodules needing removal, or in initially focused operations where it becomes necessary to perform a bilateral procedure due to disease in the opposite neck or a questionable diagnosis. Preoperative imaging tests for parathyroid localization are not absolutely necessary but may be recommended by your surgeon. An intraoperative PTH assay (test of parathyroid hormone levels) may be used as an adjunct to confirm success of surgery.

Focused or Directed

This approach involves a unilateral (one side of the neck) exploration to remove the diseased parathyroid gland. It may be performed through a small open incision or by using a video-assisted technique which uses small cameras at the end of a scope in order to visualize and remove the diseased gland. For both surgical techniques, a focused approach requires additional preoperative testing in order to "localize" which side of the neck contains the diseased gland. If imaging tests are negative (as high as 20% depending on the patient's disorder and the quality of the imaging tests) a focused approach is not possible and a traditional bilateral neck exploration is used. In order for the focused approach to be successful, additional intraoperative monitoring is also necessary in order to confirm that a patient is cured of their disease following removal of the single adenoma. The intraoperative PTH assay is used to confirm that PTH (parathyroid hormone) blood levels decrease an appropriate amount after adenoma removal to indicate cure. If this does not occur during a focused operation, it is usually indicative of other overactive parathyroid glands or hyperplasia not detected by preoperative imaging studies and necessitates a traditional, bilateral exploration (see above).

Techniques in parathyroid surgery

Focused and traditional parathyroid operations each have their own unique requisites, advantages, and disadvantages, but each may prove equally effective if applied appropriately to the individual patient in consultation with a surgeon experienced with each approach. The approach used and the condition being treated may require any one or more of the following preoperative or intraoperative techniques:

• Preoperative parathyroid localization
  • Parathyroid scan
    Necessary for focused approach
  • Neck ultrasound
    Useful for detecting parathyroid adenoma in association with significant thyroid nodules ( ~20% of patients)
  • Computerized tomography (CT scan)
    May be useful for parathyroid localization in selected cases
  • Magnetic resonance imaging (MRI)
    May be useful for parathyroid localization in selected cases
  • Invasive PTH (parathyroid hormone) venous sampling
    Used in selected cases of reoperative surgery for missed parathyroid adenomas, recurrent hyperparathyroidism, or suspected ectopic parathyroid adenoma
• Intraoperative adjuncts in parathyroid surgery
  • Intraoperative PTH (parathyroid hormone) monitoring
    PTH assay necessary for focused approach
  • Frozen section
    Selectively used to confirm parathyroid tissue and in some cases may help to confirm parathyroid hyperplasia
  • Intraoperative sestamibi probe
    Useful for localizing parathyroid adenomas by using a probe which detects a radioactive molecule administered preoperatively that accumulates in the parathyroid adenoma. Similar to preoperative parathyroid scans with similar false-negative rates. Probe-guided surgery may be more useful in reoperative cases of missed adenomas, recurrent disease, or ectopic glands.
  • Cryopreservation of parathyroid tissue
    In some cases it is beneficial to save some parathyroid tissue that was removed in order that it may be utilized in the future if a patient's parathyroid function is found to be too low following surgery (MEN and secondary hyperparathyroidism). Tissue may be frozen and stored for an individual patient and can be used at a later date if necessary.