Chapter 2. Parathyroidectomy

Symptomatic

• Fractures (especially vertebral compression fractures).
• Nephrolithiasis.
• Severe neuromuscular weakness.
• Easy fatigability.
• Loss of stamina.
• Sleep disturbance.
• Depression.
• Memory loss.
• Pancreatitis.
• History of an episode of life-threatening hypercalcemia.
• Carcinoma.

Asymptomatic

• Markedly elevated serum calcium (> 1.0 mg/dL above normal).
• Markedly elevated 24-hour urinary calcium excretion (> 400 mg).
• Abnormal serum creatinine.
• Reduced bone mineral density (T-score < −2.5).
• Age younger than 50 years.
• Carcinoma.

• Pregnancy (first trimester).
• Multiple comorbidities precluding safe intervention.
• Idiopathic hypercalcemia.

Expected Benefits

• Treatment of symptomatic hypercalcemia.
• Prevention of deleterious effects secondary to chronic parathyroid hormone elevation and hypercalcemia.

Potential Risks

• Bleeding requiring reoperation.
• Weakness of the voice or hoarseness (temporary or permanent).
• Need for oral calcium/vitamin D supplements (short or long term).
• Visible neck scar.
• Neck swelling beneath incision.
• Infection.
• Failure of operation to correct hypercalcemia or recurrence of hypercalcemia.
• Need for additional tests or procedures.

• Intraoperative parathyroid hormone (PTH) monitoring capability with access and equipment for blood sampling (peripheral or central).
• Bipolar cautery, harmonic scalpel, LigaSure, or surgical ties can be safely used for hemostatic control.

• Nothing by mouth the evening before surgery.
• No preoperative antibiotics are necessary before surgery, except when the patient has other indications (eg, cardiac valvulopathy or orthopedic hardware).
• Anesthesiology consultation as needed.

• The patient should be supine with his or her legs slightly reclined and the head and shoulders raised (lawn chair position).
• A towel roll or other small bump is placed beneath the shoulder blades to allow for neck extension and exposure.

• Local or general anesthesia may be used.
• Figure 2–1: An incision is made transversely approximately 1 cm below the level of the cricoid cartilage and measuring 3–5 cm in length.
• Figure 2–2: This incision is carried through the level of the platysma with electrocautery.
  • Subplatysmal flaps are fashioned superiorly, laterally, and inferiorly with a combination of electrocautery and blunt dissection.
  • The strap muscles and associated fascia are entered through the midline taking care to avoid injuring the anterior jugular veins.
• Figure 2–3: Dissection proceeds to include all of the soft tissue associated with the thyroid down to the prevertebral fascia.
  • The thyroid is retracted medially by the assistant; the carotid sheath is bluntly dissected on the medial aspect so it can be retracted laterally, allowing adequate exposure to identify the recurrent laryngeal nerve, which usually courses superiorly in the tracheoesophageal groove.
  • Occasionally, the middle thyroid vein must be ligated and divided.
  • At this point in the operation, a baseline PTH level is drawn and promptly placed on ice.
• Figure 2–4: The parathyroid glands are dissected free from the surrounding tissue, taking care to avoid disrupting their vascular supply.
  • An additional PTH level may be drawn before excision (by surgeon's choice) and PTH levels are also monitored 5, 10, and ...