Surgical Procedures Choosing a Surgeon

Choosing a Surgeon

Since almost half of those patients who are recommended for surgery can be successfully treated medically, the main goal of your surgeons should be to screen out those patients who do not truly need surgery. Thyroid and parathyroid surgery is a highly specialized field which can only be mastered by well trained surgeons with adequate experience with these procedures. The more training your surgeon has, the better he or she will be at determining which patients actually need surgery. When visiting a surgeon for your thyroid or parathyroid condition, keep in mind that the specific title of the surgeon is not necessarily relevant to their experience in thyroid or parathyroid surgery. For example, a head and neck surgeon may not be an expert in thyroid or parathyroid surgery. It is therefore important that you inquire about the surgeon's specific experience.

In addition, there are various options for thyroid and parathyroid surgery. We encourage all patients to research their options and discuss them with their surgeon to find out which is best for their specific condition. The more informed you are, the better your outcome will be. Below are a few questions to ask your surgeon:

Q: How many thyroid/parathyroid procedures do you perform per year?
A: Ask for specific numbers, "many" is too vague. An expert thyroid and /or parathyroid surgeon performs at least 50 thyroid/parathyroid operations per year. In addition, an expert surgeon's practice is dedicated primarily to thyroid and parathyroid cases.

Q: How many thyroid/parathyroid operations have you performed in total?
A: Because there are many rare thyroid and parathyroid conditions, the more overall experience the surgeon has, the more likely he or she is to have encountered rare conditions, such as parathyroid cancer. Use the chart below to determine the experience of your surgeon.

Q: Do you perform thyroid/parathyroid surgery under local anesthesia? If so, how many of these procedures have you done?
A: If a patient chooses local anesthesia over general, they are given a mild sedative to ease anxiety, but they are awake throughout the operation so that they can interact with the surgeon. Most patients do not experience any pain during the procedure and report a quicker post-operative recovery. If you wish to be given a local anesthetic only, a surgeon who has done at least 50 thyroid and parathyroid operations under local anesthesia would be considered to have adequate experience.

It is important to keep in mind that only surgeons who are trained to perform thyroid or parathyroid surgery using local anesthesia are doing so on a routine basis. To date, there are very few institutions which offer this training, therefore you will find that very few surgeons perform thyroid or parathyroid surgery using local anesthesia. In addition, since this has only recently been accepted as a viable alternative for thyroid and parathyroid surgery, many reputable, expert surgeons do not perform this procedure on a routine basis.

Also note that local anesthesia can be used regardless of whether or not the abnormal parathyroid gland(s) or thyroid nodule(s) was identified preoperatively.

Important Issues for Patients Undergoing Parathyroid Surgery

Q: Do you have experience performing both unilateral and bilateral approaches for parathyroidectomy under local anesthesia?
A: There are two main approaches for parathyroid surgery: unilateral (one side of the neck) and bilateral (both sides). Bilateral surgery is best for the patients who are at risk for multi-glandular parathyroid disease, which occurs in about 10-20% of patients, or for the patients who have co-existing thyroid nodules, which occurs in about 20% of patients. If you choose to have your operation done under local anesthesia, it is important that your surgeon is experienced in performing the bilateral as well as the unilateral approach under local. Often surgeons who will perform thyroid or parathyroid surgery under local will only do so unilaterally because they lack experience with the bilateral technique under local or they believe it takes too long. If you have an experienced surgeon, there is very little difference between the bilateral and unilateral approaches in terms of recovery time, hospital stay, incision size, duration of operation and complications.

About Minimally Invasive Approaches for Parathyroid Disease

It is our opinion that patients who request minimally invasive approaches under regional/local anesthesia can best achieve this by having a surgeon with a lot of experience in performing parathyroid procedures using both a minimally invasive bilateral approach or a focused unilateral approach. If the serum (blood) calcium level does not reduce in the latter approach (which occurs in 5-8% of patients), a repeat sestamibi and a second guided procedure is recommended. Patients whose abnormal parathyroid gland(s) is(are) not identified preoperatively and who still want a minimally invasive procedure under regional/local anesthesia should seek out surgeons who have experience in performing bilateral explorations under these conditions.

The principles of minimally invasive unilateral parathyroidectomy include the successful preoperative localization of a solitary adenoma (with a sestamibi scan, ultrasound, and/or thin cut CT scan), a targeted operative approach that does not disturb the normal parathyroid glands, and intraoperative confirmation of excision of all hypersecreting parathyroid tissue using a rapid parathyroid hormone (PTH) assay. The rapid PTH assay allows surgeons to assess the completeness of parathyroid resection without visualizing all the parathyroid glands. In the event that intra-operative PTH levels do not decrease during surgery, a bilateral neck exploration will be performed (under local anesthesia). Once the PTH levels normalize, the operation is concluded. Occasionally (<1%) hypersecreting parathyroid glands can be located in the mediastinum (chest) which may mandate additional procedures following your surgery. Both the bilateral approach and the unilateral minimally invasive approaches use local anesthesia, decrease the duration of surgery, and allow ambulatory surgery in most patients.

The table below outlines different aspects of the various techniques for parathyroid surgery. For further details on these techniques, see the section on parathyroid surgery.