Parathyroidectomy

Parathyroidectomy

Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.
 

Description of procedure

Parathyroidectomy is the surgical removal of one or more parathyroid glands.

The parathyroid glands are four rice-sized glands located on back of the thyroid gland in the neck. The parathyroid glands make parathyroid hormone (PTH), which controls the levels of calcium in the body.

Hyperparathyroidism (HPT) is a condition of abnormal excessive parathyroid hormone (PTH) production and a resultant calcium and phosphate disturbance.  It is broadly categorised into:  primary, secondary (e.g. chronic kidney disease), and tertiary.  Primary HPT is the commonest metabolic condition requiring surgical intervention.  Commonly, it is a result of a single hyperfunctioning adenoma (80%) and less frequently due to multiple gland hyperplasia (~15%).   Parathyroid carcinoma is a rare cause (<1%).

Operative techniques

Imaging:  

  • Extensive attempts should be made to localise the abnormal glands with concordance between two imaging modalities.  The commonest imaging techniques used are ultrasound and sestamibi-scintigraphy.  Other techniques are selectively used (e.g. CT, MRI, PET, selective venous sampling).  Localisation is seldom indicated in primary surgery for renal HPT. Localisation studies do not impact cure rates but influence the choice for targeted approach to parathyroidectomy.
  • Preoperative vocal cord check (mandatory).

Operative technique:

  • The surgical management of HPT requires a thorough understanding of the anatomy and embryology of the parathyroid glands.  The surgical approach (bilateral cervical exploration versus focused approach) may be dictated by the localisation studies and the underlying pathology.  Accurate localisation allows for the use of focused and minimally invasive techniques.
  • The open/bilateral cervical exploration remains the gold standard approach.  An open parathyroidectomy is performed through a 4-5cm.
Additional procedures that may become necessary
  • Abdominal drain insertion
  • Chest drain insertion
  • Nephrectomy
Benefits
  • Diagnostic: Provide histological diagnosis for underlying adrenal tumour development.
  • Therapeutic:  Treatment of symptomatic adrenal pathology, remove tumour from adrenal gland whether primary or secondary, restore hormonal equilibrium after surgery with medication as required.
Alternative procedures/conservative measures
  • Medical: Conservative watchful waiting with serial radiological follow-up, analgesia, hormonal and steroid therapy as necessary.
  • Surgical: Open, laparoscopic, RFA (currently in research phase).
Blood transfusion necessary
  • Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions in emergency situations.
Type of anaesthesia/sedation
  • General anaesthesia with appropriate invasive and non-invasive monitoring (central venous pressure (CVP)/arterial line).
Follow-up or need for further procedure
  • Routine postoperative surgical follow-up to ensure satisfactory healing.
  • Endocrinological follow-up for clinical and biochemical confirmation of cure (e.g. reduction in antihypertensive requirements and potassium supplementation in Conn's syndrome).
  • Short Synacthen test – indicated following unilateral adrenalectomy in Cushing's syndrome as predictor of return of contralateral adrenal function.

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