Parathyroid Exploration For Primary Hyperparathyroidism - Uptodate 2022

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Parathyroid exploration for primary

hyperparathyroidism
Parathyroid exploration for primary hyperparathyroidism
Authors:
Nancy D Perrier, MD, FACS
Paxton V Dickson, MD
Angelica Silva Figueroa, MD

Section Editors:
Sally E Carty, MD, FACS
Clifford J Rosen, MD
Deputy Editor:
Wenliang Chen, MD, PhD
Literature review current through: Feb 2022. | This topic last updated: Apr 06, 2020.
INTRODUCTION — Primary hyperparathyroidism (PHPT) is most

commonly diagnosed when hypercalcemia is detected incidentally on routine biochemical
screening [1]. Hyperparathyroidism and hypercalcemia can lead to symptoms such as
nephrolithiasis and osteoporosis. Parathyroidectomy provides definitive therapy for PHPT and is
recommended for all patients with symptomatic and familial disease and selected patients with
https://pro.uptodatefree.ir/show/15039 Página 1 de 42
asymptomatic disease.
The surgical treatment for PHPT will be reviewed here. The medical management of
hyperparathyroidism, surgical anatomy of the parathyroid glands, multiple endocrine neoplasia
type 1, and role of preoperative localization and intraoperative parathyroid hormone assay are
discussed elsewhere. (See "Surgical anatomy of the parathyroid glands" and "Preoperative
localization for parathyroid surgery in patients with primary hyperparathyroidism" and "Primary
hyperparathyroidism: Management" and "Multiple endocrine neoplasia type 1: Clinical
manifestations and diagnosis" and "Intraoperative parathyroid hormone assays".)
INDICATIONS — Once a diagnosis of primary hyperparathyroidism (PHPT)

has been made biochemically, a decision regarding surgical intervention versus observation
must be made. That decision varies depending on whether the patient is symptomatic, is
asymptomatic, or has familial disease. (See "Primary hyperparathyroidism: Management".)
Symptomatic PHPT — Surgical intervention is indicated for all patients with

symptomatic PHPT [2]. Clinical manifestations of hyperparathyroidism include [2,3] (see "Primary
hyperparathyroidism: Clinical manifestations"):
●Polydipsia and polyuria.
●Nephrolithiasis or nephrocalcinosis.
●Hypercalcuria (24 hour urine calcium level >400 mg/dL).
●Impaired renal function (glomerular filtration rate [GFR] <60 mL/minute).
●Osteoporosis (bone density score <-2.5), fragility fracture, or vertebral compression fracture.
●Pancreatitis, peptic ulcer disease, or gastroesophageal reflux.
●Neurocognitive dysfunction or neuropsychiatric symptoms attributable to PHPT.
Asymptomatic PHPT — Asymptomatic patients have a biochemical diagnosis

of PHPT but no objective features of the disease (eg, osteoporosis or nephrolithiasis). However,
completely asymptomatic PHPT is uncommon; many "asymptomatic" patients have nonspecific
or subtle symptoms, such as fatigue, depression, irritability, anxiety, anorexia, difficulty with
concentration, or memory impairment. These subjective symptoms are often difficult to quantify
and are frequently not fully appreciated until successful surgical intervention unmasks an
improvement in the complaints [4].
Indications for surgical intervention in patients with asymptomatic PHPT include [2,4-6] (see
"Primary hyperparathyroidism: Management"):
●Age <50 years.
●Serum calcium level >1 mg/dL above normal range.
●Silent nephrolithiasis or nephrocalcinosis.
●Patients who are unable or unwilling to comply with surveillance protocols.
●Patients with high risk for cardiovascular disease who might benefit from mitigation of
potential cardiovascular sequelae other than hypertension.
●Additionally, patients with clinical features such as muscle weakness, decreasing functional
capacity, abnormal sleep patterns, and fibromyalgia may also be considered for
parathyroidectomy.
Persistent or recurrent PHPT — After initial parathyroidectomy,

some patients develop persistent (<6 months from initial exploration) or recurrent (>6 months
from initial exploration) disease. If the diagnosis of persistent or recurrent PHPT is suspected, it
should be confirmed biochemically and the indications for operation considered [2,7]. Because
the risks of complications such as recurrent laryngeal nerve (RLN) injury, permanent
hypoparathyroidism, and nontherapeutic re-exploration are higher, these operations should be
performed by surgeons experienced with reoperative neck surgery [8]. It is generally
recommended that two concordant imaging studies for localization be obtained prior to re-
exploration. Another valuable technique for localization prior to re-exploration for persistent or
recurrent PHPT is ultrasound-guided fine needle aspiration of a suspected gland(s) with both
histology and parathyroid hormone (PTH) assay performed on the aspirate [9,10].
(See "Preoperative localization for parathyroid surgery in patients with primary
hyperparathyroidism", section on 'Reoperation for recurrent or persistent hyperparathyroidism'.)
Due to increased risks, the indications for reoperation are more stringent than for initial surgery
and limited to major manifestations of hypercalcemia, including [7]:
●Nephrolithiasis
●Osteoporosis
●Serum calcium level >12 mg/dL
●Hypercalciuria
●A 30 percent decrease in renal creatinine clearance
Familial PHPT — Hereditary forms of PHPT occur either as a part of a multiple

endocrine neoplasia (MEN) syndrome or as isolated familial hyperparathyroidism (FHPT). MEN
type 1-associated hyperparathyroidism usually has an earlier age of onset and is multiglandular.
(See "Multiple endocrine neoplasia type 1: Clinical manifestations and diagnosis" and "Clinical
manifestations and diagnosis of multiple endocrine neoplasia type 2" and "Treatment of
hypocalcemia", section on 'Hypoparathyroidism'.)
Surgical intervention is indicated for hereditary forms of PHPT. (See 'Familial disease' below.)
Normocalcemic PHPT — Normocalcemic PHPT is an increasingly

recognized clinical entity that remains incompletely characterized. These patients have normal
total and ionized calcium levels and inappropriately elevated PTH levels [11]. It is important to
rule out causes of secondary HPT (eg, vitamin D deficiency) in these patients.
The indications for operative intervention for normocalcemic PHPT are not defined, and
currently it is not recommended to use the same criteria used for patients with asymptomatic
hypercalcemic PHPT [12]. Observational studies indicate that some of these patients will
progress to hypercalcemic PHPT; therefore, it is important that they are followed over time
[12,13]. (See "Primary hyperparathyroidism: Management", section on 'Normocalcemic
hyperparathyroidism'.)
Parathyroid cancer — Parathyroid cancer is a rare cause of PHPT. It may be

suspected preoperatively in a patient with markedly elevated serum calcium or PTH levels,
hyperparathyroidism with a palpable or painful neck mass, imaging that shows an
inhomogeneous or large mass, or local soft tissue invasion. Parathyroidectomy is indicated
when there is suspicion for parathyroid cancer [2]. (See 'Parathyroid carcinoma' below and
"Parathyroid carcinoma", section on 'Resectable disease'.)
Parathyroid cyst — Parathyroid cysts are uncommon but can cause

hypercalcemia and other symptoms [14,15]. If noted before surgery, the cystic fluid (which is
typically clear) should be tested for PTH. Occasionally, complete resolution of the cyst can occur
with aspiration, although recurrence is likely. For patients who develop recurrences after
aspiration, the optimal treatment is surgical resection. It is important to avoid spilling cystic fluid
as this may lead to parathyroid cell seeding, also known as "parathyromatosis." (See
"Parathyroid cysts".)
Parathyroid crisis — Parathyroid crisis is characterized by severe hypercalcemia

with a serum calcium concentration >14 mg/dL (3.8 mmol/L) and dramatic symptoms including
central nervous system dysfunction, nausea, and vomiting. Because PHPT is a progressive
disease, most patients have slow, steady increases of calcium levels over time, rather than acute
spikes. (See "Primary hyperparathyroidism: Clinical manifestations", section on 'Parathyroid
crisis'.)
Emergency parathyroidectomy is indicated in patients with a parathyroid crisis. In a report of 43

patients who underwent emergency surgery for parathyroid crisis, 42 were normocalcemic in
the immediate postoperative period [16]. Ninety-three percent of patients followed long-term
remained normocalcemic; 7 percent developed recurrent hypercalcemia requiring further
intervention.
CONTRAINDICATIONS — Relative and absolute

contraindications to parathyroid surgery include:
●A known contralateral recurrent laryngeal nerve (RLN) injury or vocal cord dysfunction is a
relative contraindication to neck exploration for parathyroidectomy, because bilateral RLN injury
can be life-threatening. (See 'Recurrent laryngeal nerve injury' below.)
●Symptomatic cervical disc disease is a relative contraindication to neck exploration because of

the mild neck extension necessary in positioning patients for thyroid and parathyroid surgery.
Hyperextension may potentially cause spinal cord injury in patients with cervical disc disease.
Thus, if cervical disc disease is present, it should be evaluated and in some cases corrected by an
orthopedic surgeon or neurosurgeon prior to parathyroidectomy. (See "Evaluation of the adult
patient with neck pain".)
●Familial hypocalciuric hypercalcemia (FHH) is an absolute contraindication to parathyroid

surgery. These patients do not have primary hyperparathyroidism (PHPT), and surgical
intervention does not result in cure. FHH is an autosomal dominant inherited disorder that often
leads to unnecessary parathyroid surgery. The disease is suspected when persistent, mildly
elevated serum calcium levels and a high-normal or mildly elevated parathyroid hormone (PTH)
level are noted in association with normal renal function and low 24 hour urine calcium
excretion (urine calcium/creatinine ratio <0.01). The low urinary calcium level (<100 mg/24 hours)
is the mainstay of the diagnosis. FHH results from a higher renal set point for calcium excretion.
(See "Disorders of the calcium-sensing receptor: Familial hypocalciuric hypercalcemia and
autosomal dominant hypocalcemia".)
PREOPERATIVE EVALUATION AND

MANAGEMENT — Prior to parathyroid surgery, the surgeon must perform
an initial evaluation that includes history, review of any medications that can cause
hypercalcemia, review of systems, physical examination, and review of the biochemical diagnosis
[17,18]. Error in diagnosis is a major cause of failed surgical exploration. (See "Primary
hyperparathyroidism: Diagnosis, differential diagnosis, and evaluation".)
Pertinent clinical history includes a family history of primary hyperparathyroidism (PHPT),

exposure to head and neck radiation or nuclear fallout [19,20], and a history of prolonged
lithium use [21,22]. A personal or family history of other endocrinopathies may suggest a
familial form of hyperparathyroidism [2]. Genetic counseling should be offered to patients with
PHPT who are <40 years of age, have multigland disease, or have a family history or syndromic
manifestations [2]. In a case series of 939 patients referred for surgery for apparent sporadic
hyperparathyroidism, multiple endocrine neoplasia type 1 was identified in 4.5 percent [23]. (See
"Multiple endocrine neoplasia type 1: Clinical manifestations and diagnosis" and "Clinical
manifestations and diagnosis of multiple endocrine neoplasia type 2".)
For patients with asymptomatic PHPT, a review of systems should focus on gastrointestinal
symptoms such as dyspepsia and constipation; cognitive symptoms such as depression,
emotional lability, poor memory or concentration, and disturbed sleep (due to nocturia); and
musculoskeletal symptoms such as generalized weakness, muscle aches, or easy fatigue.
Laboratory evaluation should include serum calcium, parathyroid hormone (PTH), 25-
hydroxyvitamin D, and creatinine levels, as well as 24 hour urinary calcium and creatinine levels
[2]. Because hyperthyroidism can complicate parathyroid exploration, a preoperative thyroid
stimulating hormone (TSH) level and T4 level should also be obtained [24].
Imaging should focus on evaluation of potential end-organ damages caused or exacerbated by

PHPT. Silent nephrolithiasis or nephrocalcinosis in patients with PHPT may be detected by renal
ultrasound, noncontrast computed tomography (CT), or plain abdominal radiographs [2,25].
Dual-energy X-ray absorptiometry (DXA) should be performed to evaluate for osteopenia or
osteoporosis. Bone density measurements should be obtained at the lumbar spine, hip, and
distal one-third of the radius [25].
Cervical ultrasound is recommended to not only localize parathyroid disease but also assess for
concomitant thyroid pathology [26]. Patients with thyroid disease may undergo concomitant
thyroid resection at the time of parathyroidectomy after an appropriate workup [2].
Patients undergoing a focused parathyroidectomy for PHPT should undergo a preoperative

parathyroid localization study. (See 'Preoperative localization' below and "Preoperative
localization for parathyroid surgery in patients with primary hyperparathyroidism".)
Patients with PHPT who present with hypercalcemic crisis should be medically managed,
followed by parathyroidectomy [2]. With fluids and other contemporary medications, rarely, if
ever, is "emergency" parathyroidectomy necessary. (See "Treatment of hypercalcemia", section
on 'Severe hypercalcemia'.)
Prior to parathyroidectomy, patients with PHPT who are vitamin D deficient can safely begin
vitamin D supplementation, particularly those with serum markers suggestive of high bone
turnover, serum markers such as bone-specific alkaline phosphatase, N-terminal propeptide of
type 1 procollagen (P1NP), and C-terminal cross-linking telopeptide of type 1 collagen (CTX)
[2,27,28]. (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment",
section on 'Vitamin D replenishment'.)
CHOICE OF PROCEDURE — Once the decision to perform a

parathyroid operation is made, the surgeon must decide whether a standard bilateral neck
exploration or a more focused parathyroidectomy is appropriate. The goal of parathyroid

surgery is durable biochemical cure. Although cure is technically defined as eucalcemia at six
months postoperatively, in the vast majority of patients, lifelong eucalcemia is expected. In order
to ensure the best postoperative outcome, careful considerations should be given to patient
history when deciding on the operative approach. (See 'Preoperative evaluation and
management' above.)
Approximately 15 percent of patients with primary hyperparathyroidism (PHPT) have hyperplasia

or double adenoma. For patients with multigland disease, the traditional standard surgical
approach of bilateral neck exploration remains the procedure of choice [2,29,30].
In a retrospective study of 5597 patients who underwent initial parathyroidectomy for PHPT by
high-volume surgeons participating in the Collaborative Endocrine Surgery Quality Improvement
Program (CESQIP), about 30, 60, and 11 percent of patients underwent bilateral exploration,
focused exploration, and focused converted to bilateral exploration, respectively [31]. Despite
localization of an apparent single parathyroid focus by ultrasound (87 percent), sestamibi (66
percent), and computed tomography (CT) scan (20 percent), bilateral neck exploration was
required in 40 percent of patients. A quarter of focused explorations were converted to bilateral
explorations, most commonly due to concern for failure and/or lack of intraoperative PTH drop;
intraoperative PTH assay was used in over 90 percent of cases. Two or more glands were
removed in 57 percent of bilateral exploration cases.
However, with experience and improved availability of excellent imaging modalities, focused
parathyroidectomy has emerged as the procedure of choice for patients who have a localized
single adenoma and is as effective as bilateral cervical exploration in select patients. In many
high-volume centers, focused exploration remains common, aided by excellent imaging.
Bilateral parathyroid exploration — Bilateral parathyroid

exploration is a standard technique in which all parathyroid glands are identified with
exploration of the expected locations [2]. It has been well demonstrated to exclude or identify
multigland disease with high surgical cure rates (95 to 99 percent). It is a time-tested standard of
efficacy and safety in the definitive treatment of PHPT.
Bilateral parathyroid exploration is the preferred operative strategy when intraoperative

parathyroid hormone (IOPTH) monitoring is not available or at the discretion of the surgeon. A
low threshold to either begin with or convert to a bilateral parathyroid exploration is warranted
in the following situations:
●When preoperative imaging studies fail to localize a single adenoma or detect bilateral foci.
Such findings on preoperative imaging preclude a focused approach.
●When patients have familial PHPT. Such patients predictably have involvement of multiple
glands. A bilateral parathyroid exploration should also be considered for young men with
apparent sporadic PHPT, as some of them may have undiagnosed multiple endocrine neoplasia
(MEN) syndrome type 1 [23]. (See "Multiple endocrine neoplasia type 1: Treatment", section on
'Surgical approach'.)
●When concomitant thyroid disease requires surgical resection (eg, biopsy-proven papillary
thyroid cancer). (See "Preoperative localization for parathyroid surgery in patients with primary
hyperparathyroidism", section on 'Imaging modalities'.)
●When the patient is pregnant and the available localization studies require radiation. However,
if ultrasonography expertise is available and the results show an apparent single adenoma, a
focused approach can be pursued. (See "Primary hyperparathyroidism: Management", section
on 'Pregnancy'.)
●When the patient has lithium-associated hyperparathyroidism. Lithium-associated PHPT has a

high chance of having multigland involvement [32,33]. However, if preoperative imaging
localizes to a single adenoma and IOPTH monitoring is available, a focused approach may still be
pursued [2,33].
Focused parathyroid exploration — Focused parathyroidectomy

is ideally employed in patients who appear clinically and by imaging to have a single parathyroid
adenoma. It is not recommended for patients with known or suspected multigland disease [2].
This approach is appropriate for patients with unequivocal imaging suggesting unilateral
pathology, no suggestion of concomitant thyroid disease requiring surgical intervention, and no
family history of MEN syndromes. When preoperative localization studies do not identify an
adenoma or the adenoma cannot be found during focused parathyroid exploration, bilateral
parathyroid exploration must be performed. Thus, focused parathyroidectomy should be
performed by surgeons who are also experienced in performing bilateral neck exploration
[34,35].
When performed with IOPTH monitoring, focused parathyroidectomy results in excellent

outcomes that are comparable to those of the traditional bilateral cervical exploration [36-39].
The smaller incisions and less extensive dissection required for focused parathyroidectomy can
also lead to less postoperative pain, less scar tissue, and a lower incidence of hypocalcemia from
ischemia of other glands.
Although there are few randomized trials comparing focused parathyroidectomy with the
traditional bilateral approach, cure rates appear to be similar when the two procedures are
performed by experienced endocrine surgeons [30,40-45]. Compared with bilateral exploration,
focused parathyroidectomy had similar recurrence (0.8 versus 1.25 percent), persistence (2.4
versus 2.3 percent), and reoperation rates (1.3 versus 2.2 percent) but a shorter mean operative
time (102.5 versus 64.2 minutes) and lower overall complication rates (17.1 versus 3.7 percent),
according to a 2017 systematic review and meta-analysis of 19 comparative studies (over 12,000
patients) of the two approaches [46]. The lower complication rate was primarily driven by a lower
transient hypocalcemia rate (13.2 versus 1.6 percent).
Endoscopic or video-assisted
parathyroidectomy — Video-assisted or endoscopic approaches for
parathyroidectomy have been advocated by some for the management of PHPT (figure 1)
[47,48]. Candidates for an endoscopic parathyroidectomy are patients with sporadic PHPT and
unequivocal preoperative localization studies. Contraindications include prior extensive neck
surgery, hereditary PHPT, large goiters, multigland disease, obesity, and suspicion of parathyroid
carcinoma.
Except for a shorter length of incision, video-assisted parathyroidectomy does not offer
significant advantages over open focused parathyroidectomy and should only be performed by
surgeons who have first mastered the standard open operation. A randomized trial of 143
patients who underwent open parathyroidectomy (75 patients) or one of the two video-assisted
approaches (68 patients) showed no significant difference in conversion rates or outcomes. The
open surgery took less time than the video-assisted techniques (60 versus 84 minutes) [49].
Two approaches have been described for video-assisted parathyroidectomy [50]. One is a lateral
endoscopic approach using 8 to 10 mmHg carbon dioxide. The other is a central gasless
approach using a 30° 5 mm endoscope [47-52].
Surgeons should choose an operative approach that, in their hands, carries a high cure rate, low
risk profile, and comparable cost to other available techniques [2].
SURGEON'S SAFETY CHECKLIST FOR

PARATHYROID EXPLORATION
●Consent – The surgical consent should include the possibility of operative failure, transient or
permanent paralysis of one or both vocal cords, a change in voice quality and strength, transient
or permanent hypoparathyroidism, wound infection, and intraoperative or postoperative
bleeding. (See 'Complications' below.)
●Medical records – Prior laboratory reports should be reviewed to confirm the diagnosis based
on biochemical parameters. Available documentation of preoperative vocal cord evaluation and
any prior neck surgery (eg, thyroidectomy, an anterior approach to cervical disc repair, or
tracheostomy) should also be reviewed.
●Imaging studies – Imaging studies should be reviewed, and pertinent images should be
immediately available to the surgeon in the operating room to confirm the location of the
abnormal parathyroid glands. (See 'Preoperative localization' below.)
●Parathyroid hormone monitoring – If intraoperative parathyroid hormone (PTH) monitoring

is employed, adequate peripheral access typically by peripheral intravenous catheter (or arterial
line) should be secured for intraoperative blood draws. Alternatively, blood samples can be
obtained from direct venipuncture of the ipsilateral internal jugular vein. Appropriate tubes and
arrangements for transport of blood to the lab should be arranged prior to the start of the
operation. (See 'Intraoperative parathyroid hormone monitoring' below.)
●Frozen section – Expert frozen section pathologic analysis should be available. (See
"Thyroidectomy", section on 'Intraoperative frozen section analysis'.)
●Nerve monitoring – Preoperative voice evaluation should include specific inquiries about
subjective voice changes. Patients who are hoarse, have a history of prior anterior cervical
surgery, or have a suspected recurrent laryngeal nerve (RLN) dysfunction should undergo a
formal evaluation with laryngoscopy. Intraoperative nerve monitoring is typically used for
complex or reoperative cases or at the discretion of the operating surgeon [53]. (See
"Thyroidectomy", section on 'Intraoperative nerve monitoring'.)
●Antibiotics – Parathyroid surgery is a clean procedure in a well-vascularized area; thus,

postoperative infections are rare [54]. However, a dose of prophylactic antibiotic, such as
cefazolin, can be given to patients who are immunocompromised or with comorbidities that
could increase their risk of infection [55,56]. Prophylactic antibiotics should be administered
within one hour prior to incision [57-59]. (See "Antimicrobial prophylaxis for prevention of
surgical site infection in adults".)
●Anticoagulation – Most parathyroidectomies are elective. Thus, any bleeding diatheses,

thrombocytopenia, or platelet dysfunction can be addressed prior to surgery. Additionally,
medications such as warfarin, clopidogrel, aspirin, nonsteroidal anti-inflammatory drugs
(NSAIDs), and vitamin E should be discontinued prior to parathyroid surgery to minimize the risk
of cervical hematoma. The perioperative management of anticoagulation is reviewed elsewhere.
(See "Perioperative management of patients receiving anticoagulants".)
●Deep venous thrombosis prophylaxis – Patients undergoing general anesthesia should

receive primary prophylaxis against deep venous thrombosis such as sequential compression
devices. Patients should also be encouraged to ambulate the night of surgery. (See "Prevention
of venous thromboembolic disease in adult nonorthopedic surgical patients".)
●Surgical timeout – A surgical timeout should be called with the participation of the entire
operating room team (anesthesiologist, surgeon, nurse, scrub technician) to assure correct
patient identity, laterality, and intended operation as well as to verify the informed consent.
SURGICAL MANAGEMENT — The challenges of

parathyroidectomy include the wide variability in parathyroid gland anatomy between patients,
the limitations of localization studies, and the possibility of having more than four parathyroid
glands (supernumerary glands). Accordingly, judicious dissection informed by thorough
knowledge of the wide anatomic and embryologic variations in gland locations is necessary to
find an enlarged gland or glands, manage multigland disease, and deduce the presence of a
supernumerary gland. The experienced endocrine surgeon can accurately recognize size and
shape differences among parathyroid glands and reliably estimate their weights. In addition, the
surgeon must be able to intraoperatively recognize and properly treat parathyroid carcinoma.
(See "Surgical anatomy of the parathyroid glands" and "Preoperative localization for parathyroid
surgery in patients with primary hyperparathyroidism".)
Parathyroidectomy is an operation that is well documented to exhibit high-volume expertise (ie,

to have better outcomes when performed by surgeons who have a thorough understanding of
the disease and distinct experience managing patients with sporadic adenomas, multigland
disease, hereditary hyperparathyroidism (HPT), parathyroid carcinoma, and persistent or
recurrent primary hyperparathyroidism [PHPT]). Several studies have demonstrated higher cure
rates, fewer complications, lower cost, and shorter length of stay when parathyroid surgery is
performed by high-volume surgeons and in high-volume centers [2,60-62]. It is the authors'
recommendation that parathyroidectomy be performed by surgeons who perform no fewer
than 10 procedures and ideally ≥50 procedures per year.
As follows, the techniques of bilateral parathyroid exploration and focused parathyroidectomy

are described in detail separately. Steps common to both techniques are described in the
bilateral parathyroid exploration section and not repeated in the focused parathyroidectomy
section.
Bilateral parathyroid exploration

Anesthesia — Both general endotracheal anesthesia and local analgesia with monitored
anesthesia care can be utilized for parathyroid exploration. The choice should be driven by
experience and comfort level of the surgical and anesthesia teams. An oral or nasogastric tube,
an esophageal stethoscope, or a temperature probe may be placed in the esophagus to
facilitate digital palpation of a gland deep in the tracheoesophageal groove. A tube in the
esophagus provides a solid, consistent structure against which the mobile, enlarged parathyroid
gland can be palpated.
Positioning — The patient is positioned on the operating table in the semi-Fowler

position with both arms tucked. A roll can be placed transversely under the scapulae to put the
neck in mild extension, which increases exposure of the region posterior to the
tracheoesophageal groove (figure 2). Care should be taken to prevent overextension of the neck,
which can lead to vertigo, headache, and postoperative nausea. The head of the operating table
is tilted up by approximately 30 degrees (reverse Trendelenburg).
The skin should be prepped from the lower lip/angle of the mandible to the anterior chest.
Mediastinal exploration, though rarely needed, should only be performed after preoperative
discussion with the patient and operating room staff. If it is contemplated, the entire chest
should be prepped into the operative field.
Incision — If a bilateral exploration is planned, a 3 to 5 cm transverse incision is usually

made 2 cm above the clavicular head. Efforts should be made to place this incision in a skin
crease, if possible. A longer incision may be needed if the patient is obese, the gland is large, or
the neck is foreshortened as with kyphoscoliosis (figure 3). Preemptive analgesia with a local
anesthetic before incision is helpful in postoperative management of pain.
Dissection — The platysma is divided transversely and the median raphe longitudinally.
The strap muscles on the side of dissection are elevated off the thyroid lobe. In planned bilateral
exploration, the initial laterality of dissection may be guided by thyroid pathology or surgeon
preference.
Parathyroid exploration begins after inspection of the ipsilateral thyroid lobe. The lobe is
retracted anterior-medially. At all times, the surgeon should be cognizant of the course of the
recurrent laryngeal nerve (RLN) and strive to maintain excellent hemostasis of the surgical field
(figure 4).
Exploration — The lateral, inferior, and posterior surfaces of the thyroid lobe, and the
tracheoesophageal groove, are palpated to search for an enlarged gland (picture 1). Normal and
enlarged parathyroid glands are usually soft, have a yellow-brown color, and can be found
nested within a lobule of surrounding yellow adipose or thymic tissue. A single hilar vascular
pedicle is frequently a visual clue to the gland and must be carefully preserved.
While parathyroid adenomas are classically described with respect to their superior, inferior, or
supernumerary embryologic origin, a classification scheme that utilizes details of preoperative
imaging and intraoperative anatomic findings has been described [63].
The most common locations of parathyroid adenomas should be explored in a logical order,
from superficial to deep. Areolar tissue between the thyroid and carotid sheath is gently swept
laterally (figure 5). To find an enlarged superior parathyroid gland, the undersurface of the
superior pole of the thyroid lobe is also inspected. Exploration continues until the first enlarged
parathyroid gland is identified, while taking note of the locations of normal/suppressed
parathyroid glands as well.
First gland — Once identified, a first enlarged parathyroid gland is dissected

circumferentially and isolated on its vascular pedicle, with great care not to rupture its capsule.
Manipulating the connective tissue around the enlarged gland is preferable to direct handling of
the parathyroid as capsular rupture is a cause of parathyromatosis or seeding of
hyperfunctioning parathyroid tissue in the soft tissues of the neck and/or mediastinum.
Overgrowth of spilled parathyroid tissue can cause recurrent hyperparathyroidism [64,65].
Starting dissection from the lateral aspect of an adenoma helps the surgeon appreciate the full
extent and size of an adenoma visually as "the tip of the iceberg." Prior to division and ligation of
the vascular pedicle, it is imperative to confirm safety of the ipsilateral RLN (figure 6). Enlarged
parathyroid glands can sometimes be wedged between the RLN and the trachea at the ligament
of Berry and must be freed by gently dissection.
Upon excision and inspection of the suspected adenoma, all resected parathyroid tissue should
be measured and weighed. In evaluating the first resected gland, a weight of <200 mg is likely
associated with both multigland disease and operative failure [66]. When in doubt, frozen
section analysis may be utilized to confirm that the specimen is in fact parathyroid tissue.
Ectopic thyroid tissue, thyroid nodules, and lymph nodes can easily resemble an enlarged
parathyroid gland, especially in a reoperative case or when the patient has concomitant
thyroiditis. In vivo or ex vivo parathyroid hormone (PTH) aspiration may also be used to confirm
the tissue origin of the specimen. Direct fine needle aspiration of the excised gland's
parenchyma can be performed with a 21 to 24 gauge needle attached to a small syringe. The
aspirate is sent for intraoperative PTH assessment in a small amount of saline, usually 1 cc, and
values that are exceedingly high or above the upper limit of the assay are highly suggestive of
parathyroid tissue.
Second gland — After resecting the first enlarged gland, many surgeons search for
the second ipsilateral parathyroid gland. A normal parathyroid gland weighs 35 to 50 mg. In
primary hyperparathyroidism, a "suppressed" normal gland can be even smaller. Routine biopsy
of normal glands is not recommended. When in doubt, shave or hemi-biopsy of the second
ipsilateral gland can be accomplished by gently applying a titanium clip to the distal edge of the
gland opposite the vascular pedicle and sharply excising a 5 to 15 mg fragment, which is then
weighed and assessed by pathology. Care should be taken not to disrupt the vascular pedicle or
to devascularize the gland.
Multigland disease — If the second parathyroid gland ipsilateral to the first is

enlarged, the diagnosis of multigland disease is made, and multigland resection should be
performed after a four-gland exploration [2]. Double adenomas are rare (<6 percent) but do
occur. Inspection of all four glands allows for double adenomas to be distinguished from four-
gland hyperplasia. Double adenomas can be treated with removal of just two glands.
For patients who have multiple enlarged glands, it is important to visualize all the glands before
a final decision is made on which glands are to be removed. In patients with four-gland
hyperplasia, all but a portion of one enlarged gland is removed, leaving a well-vascularized
parathyroid remnant of 50 to 100 mg size. This is referred to as a subtotal or three-and-half-
gland resection. The parathyroid remnant should be marked with a titanium clip or Prolene in
case reoperation is required. Viability of the intended remnant is checked before the remaining
enlarged glands are resected. (See "Parathyroidectomy in end-stage kidney disease", section on
'Subtotal parathyroidectomy'.)
Another approach, which has fallen into disuse in familial PHPT but is still used by some experts
in dialysis patients with secondary/tertiary HPT, is to remove all four glands and autotransplant
parathyroid tissue into the forearm, where it is more accessible in case of recurrent disease [67].
Total parathyroidectomy with autotransplantation can lead to temporary vitamin D and calcium
dependency due to a lack of functional PTH [68]. It is not recommended for first-time operations
in familial PHPT, secondary, or tertiary HPT patients, because it can result in severe
hypocalcemia that is extremely difficult to manage and life-threatening. (See "Parathyroidectomy
in end-stage kidney disease", section on 'Total parathyroidectomy with heterotopic
autotransplantation'.)
Some centers cryopreserve parathyroid tissue in the event that the remnant or autotransplanted
tissue becomes devascularized or dysfunctional, which renders the patient aparathyroid.
Cryopreservation, however, requires preoperative planning for tissue transport and storage and
is costly. With regard to tissue maintenance, there is no role for cryopreservation in primary
operations. (See "Parathyroidectomy in end-stage kidney disease", section on
'Cryopreservation'.)
Missing gland — A missed parathyroid adenoma is the most common cause for
persistent hyperparathyroidism. During bilateral parathyroid exploration, the surgeon must use
his/her knowledge of the embryology and anatomy of the parathyroid glands to determine
whether a superior or an inferior gland is missing, or a supernumerary gland is present (figure
7), and use that information to conduct an orderly search for the missing gland.
Missing superior gland — For a missing superior gland, the surgeon should explore
the middle and posterior neck compartments, particularly the paraesophageal spaces and the
tracheoesophageal groove, extending the dissection caudad into the middle and posterior
mediastinal planes (figure 8).
The surgeon must confirm that there is not an enlarged gland in the paraesophageal or
retroesophageal space, which is the most common place for missed superior glands. Such
glands can often descend in the avascular plane to reside in a location inferior to the inferior
gland and are posteriorly located along the lateral border of the esophagus. Digital palpation
along the lateral border of the esophagus is an excellent way to identify the gland, which can be
appreciated as a subtle bulge.
The superior thyroid vessels can be followed superiorly to assess for a partially undescended
gland, palpating the piriform sinus and angle of the jaw cranial to the superior pole of the
thyroid. The missing superior gland may also be found in the posterior retropharyngeal space.
The majority of mediastinal parathyroid glands (over 90 percent) are accessible via a cervical
approach. A partial median sternotomy or thorascopic approach should be reserved for
reoperation after localization studies have identified a mediastinal gland.
Missing inferior gland — For a missing inferior gland or supernumerary gland, the
surgeon should explore the ipsilateral thymus and upper cervical region, dissecting into the
anterior, superior mediastinum via a cervical approach. Missing inferior glands may sometimes
be palpated by sweeping a finger from lateral to medial on the periosteum behind the
manubrium.
Many missing inferior parathyroid glands will be located within the thymus, and most
intrathymic enlarged glands can be removed with a cervical approach. A cervical thymectomy
may need to be performed. The thyrothymic ligament must be carefully handled in order to
prevent fracture division or retraction of the thymus into the mediastinum. The resected thymus
should be manually inspected and palpated in an ex vivo fashion and further evaluated with
frozen section because a normal or enlarged parathyroid gland may not be readily visible.
If exploration is still unrevealing, the carotid sheath is entered sharply and meticulously explored
to assess for an undescended parathyroid gland (figure 9). Care should be taken to avoid
damage to the vagus nerve. Exploration of the carotid sheath should extend from the clavicle to
the bifurcation of the common carotid artery. Although rarely indicated, an ipsilateral thyroid
lobectomy may be performed if an intrathyroidal parathyroid gland is suspected; approximately
1 percent of inferior gland adenomas are intrathyroidal.
Missing supernumerary gland — Most supernumerary parathyroid glands are

within the thymus [69,70]. In the search for a missing enlarged gland, a cervical thymectomy
should be performed. Supernumerary glands can also be found along the anterior surface of the
carotid sheath and near the tubercle of Zuckerkandl. The surgeon should explore the bilateral
carotid sheaths and palpate the piriform sinuses. Preoperative or intraoperative thyroid
ultrasound can also help identify an intrathyroidal parathyroid adenoma. (See "Overview of the
clinical utility of ultrasonography in thyroid disease".)
When an enlarged gland cannot be located in any of the normal or ectopic positions despite a
systematic and thorough search, the surgeon must concede that a curative operation is not
possible, and the surgical procedure should be concluded. Before that, PTH levels can be
obtained via bilateral jugular venous sampling and used to lateralize the missing gland to one
side of the neck [71]. If a reoperation is contemplated, the diagnosis of PHPT should be
reconfirmed biochemically and additional localization studies performed. (See 'Intraoperative
parathyroid hormone monitoring' below.)
Compromised gland — Although only one normal parathyroid gland is necessary

for maintaining calcium homeostasis, removal of normal parathyroid glands should be avoided.
If a normal parathyroid gland becomes severely ischemic during dissection or is excised
accidentally, immediate autotransplantation is recommended [2].
If there is uncertainty about the tissue of origin, the surgeon should send a 1 mm sliver of tissue
for frozen section analysis and store the remainder of the specimen in chilled Tis-U-Sol or
normal saline solution in the interim.
To perform parathyroid autotransplantation, a small pocket is created in the designated muscle,

either the nondominant forearm or the ipsilateral sternocleidomastoid muscle, using a right
angle clamp. After ensuring hemostasis, the parathyroid tissue is minced into multiple 1-mm-
sized fragments and inserted into the single muscle pocket. Two small hemoclips can be used to
tag and close the pocket.
Alternatively, cryopreservation is available at some centers and is useful in some patients to

avoid permanent hypoparathyroidism, particularly in the setting of reoperative parathyroid
surgery [72,73].
Familial disease — For patients with hereditary forms of PHPT, the amount of
parathyroid tissue removed varies with the cause of hyperparathyroidism [74-76]:
●For patients with multiple endocrine neoplasia (MEN) type 1-associated PHPT, the initial
surgical procedure usually includes resection of three-and-one-half hyperplastic parathyroid
glands (subtotal resection) with strong consideration for concomitant cervical thymectomy [2].
●For patients with MEN type 2A-associated PHPT, parathyroid hyperplasia is heterogeneous.
Thus, although bilateral exploration is usually performed as the initial procedure, only the visibly
enlarged glands are resected [2]. (See "Multiple endocrine neoplasia type 1: Clinical
manifestations and diagnosis" and "Clinical manifestations and diagnosis of multiple endocrine
neoplasia type 2".)
For patients with MEN type 2A-associated recurrent hyperparathyroidism, a complete

parathyroidectomy with forearm autotransplant is typically performed. This more aggressive
surgical approach is warranted because patients with MEN type 2A may develop medullary
thyroid carcinoma with cervical metastases. Autotransplanting the parathyroid tissue to a
distant site eliminates the risk of devascularization, should another cervical reoperation be
needed. Recurrent hyperparathyroidism due to overgrowth of a forearm autograft can be tested
by measurement of PTH in the antecubital vein. This can then be treated by graft removal under
local anesthesia after localization of the site with ultrasound imaging. However, if the autograft
fails to function, the patient may have permanent hypoparathyroidism (or aparathyroidism). The
risk of hypoparathyroidism is higher with autotransplantation than with leaving the parathyroid
gland in situ.
Parathyroid carcinoma — Parathyroid carcinoma is a rare cause of primary

hyperparathyroidism. It is difficult to distinguish from parathyroid adenoma based on
preoperative evaluation but may be suggested by one of the following findings during
parathyroid exploration:
●A solitary tumor greater than 3 cm in diameter [77].
●A firm, irregular, lobulated mass [78].
●A dense, fibrous capsule surrounding the tumor producing a white or gray-brown tint [78,79].
●Invasion of or adhesion to surrounding structures, including the ipsilateral thyroid lobe, strap
muscles, RLN, esophagus, or trachea [77,80,81].
●Lymph node metastasis (present in <5 percent of parathyroid cancer cases) [82].
●Cystic features.
The presence of these operative findings in patients with preoperative calcium levels greater
than 14 mg/dL and parathyroid hormone levels >3 times the normal value are reasons for
suspicion of parathyroid carcinoma [80,83].
A suspected parathyroid carcinoma should be completely resected, which may require en bloc
resection of the ipsilateral thyroid lobe and adherent tissues. Although formal bilateral central
lymph node dissection is not recommended, clearance of the ipsilateral central neck may allow
for optimal clearance of soft tissues of the side of the carcinoma. The RLN can be preserved
unless it is circumferentially involved [77,78,84,85]. It is important to avoid capsular violation or
tumor spillage (eg, with biopsy) [77,78,82,83,86-89]. Because lymph node involvement is
uncommon, a modified lateral neck dissection is not required in the absence of clinical nodal
involvement, which is rare [2,82]. The diagnosis of parathyroid carcinoma relies on the histologic
identification of unequivocal angioinvasion and can be assisted by biomarkers.
A complete surgical resection (R0 resection) is the only cure for parathyroid cancer and has been
shown to reduce complications and improve quality of life [78,80,90-92]. Adjuvant external beam
radiation should be reserved for palliation and is not routinely given after surgical resection of a
parathyroid carcinoma [2,93]. (See "Parathyroid carcinoma", section on 'Resectable disease'.)
Closure — The strap muscles are reapproximated with interrupted absorbable sutures to
cover the trachea. The platysma is then reapproximated with interrupted absorbable suture. The
skin is typically closed with a running subcuticular absorbable suture. A drain is not required.
Documentation — The operative report should detail the findings and events of
parathyroidectomy. It is useful to have lateralized templates or drawings of cervical structures
on which to place an excised gland to show its location at the time of surgery. The excised gland
can be photographed on this template, made a permanent part of the medical record, and be
available for future reference in the event of persistent or recurrent disease. Alternatively, the
surgeon can include a drawing of the operative findings in the written operative report [63].
Focused parathyroidectomy — The success of a focused

parathyroidectomy is predicated upon preoperative localization studies that permit the surgeon
to limit the operative field to the region where a single radiologic focus has been identified and
combined with intraoperative PTH monitoring that is suggestive that no other hyperfunctional
parathyroid tissue remains. In other words, localization results inform the surgeon where to
start looking for the adenoma, and intraoperative PTH results can suggest to her/him when to
stop looking. (See "Preoperative localization for parathyroid surgery in patients with primary
hyperparathyroidism" and 'Intraoperative assessment' below.)
Preoperative localization — Parathyroid localization studies are an integral

part of a focused parathyroid exploration. Localization studies should only be performed to help
plan an intended operation after the biochemical diagnosis has been confirmed. The role of the
imaging is to suggest where to start the surgical dissection, rather than to make the diagnosis
or decide whether to intervene with parathyroidectomy. (See 'Preoperative evaluation and
management' above.)
Commonly used localization studies include cervical ultrasound, sestamibi scan, and multiphase
contrast-enhanced computed tomography (CT) of the neck (commonly referred to as four-
dimensional CT). Patients who are candidates for parathyroidectomy should be referred to
expert clinicians to decide which imaging studies to perform based on their knowledge of local
imaging capabilities. The expertise of the local radiologist in study selection is also important
since interpretation of studies is often user dependent. (See "Preoperative localization for
parathyroid surgery in patients with primary hyperparathyroidism".)
Patients who are candidates for surgery based on a complete biochemical workup and who have
negative or discordant imaging should always be referred to a parathyroid surgeon for
evaluation. Because capsular fracture can potentially cause histologic changes similar to those
of atypia, preoperative parathyroid fine needle aspiration is not recommended except in
unusual, difficult cases of PHPT and should not be performed if parathyroid cancer is suspected
[2]. (See "Primary hyperparathyroidism: Diagnosis, differential diagnosis, and evaluation".)
If a bilateral parathyroid exploration is planned, then there is little role for preoperative
localization studies since all parathyroid glands will be visualized. However, cervical ultrasound is
frequently used to identify concomitant thyroid abnormalities that may need to be addressed at
the same operation. (See "Preoperative localization for parathyroid surgery in patients with
primary hyperparathyroidism" and 'Preoperative evaluation and management' above.)
Intraoperative assessment — Intraoperative parathyroid hormone (IOPTH)

monitoring provides real-time confirmation of surgical cure. In the past, a radioguided approach
was advocated by a select few to enhance focused dissection and allow ex vivo confirmation that
a sestamibi-avid gland had been removed [94]. IOPTH monitoring and the radioguided probe
may be used in tandem.
Intraoperative parathyroid hormone monitoring — IOPTH monitoring

provides a useful tool to indicate when all hyperfunctioning parathyroid tissue has been
adequately excised. When focused parathyroidectomy is planned, the use of IOPTH is suggested
to avoid high operative failure rates [2].
IOPTH monitoring takes advantage of the short plasma half-life of PTH (three to five minutes)
and a rapid assay that produces measurements while the patient is still in the operating room
[34,95-97]. A baseline PTH value is obtained at the start of the procedure, prior to skin incision.
PTH levels are then measured following removal of the suspected adenoma [71]. A reduction of
at least 50 percent in PTH level from the baseline (the ">50 percent PTH drop criteria") is an
accepted standard for intraoperative confirmation of success, although a number of centers
further require that the postexcision PTH level also be within the normal range (the "Dual
criteria") [2,98,99]. The combination of a post-resection IOPTH that is within the normal range
and has dropped by >50 percent of baseline does not define cure, but has been shown to be a
strong predictor of cure [100]. Surgeons utilizing IOPTH monitoring should employ a sampling
protocol that is reliable in the local environment and should be familiar with the interpretation of
PTH decay dynamics [2]. (See "Intraoperative parathyroid hormone assays".)
Blood sample for IOPTH monitoring may be obtained from a peripheral vein or an arterial line.
For localization of a missing gland, samples from bilateral jugular veins can be assayed at the
time of exploration; a unilateral elevation is suspicious for a missing hyperfunctioning gland on
that side, while comparable PTH levels from both sides may suggest hyperfunctioning
parathyroid disease in the mediastinum. (See 'Missing gland' above.)
False-positive IOPTH results (ie, a >50 percent decrease intraoperatively) followed by recurrent
hyperparathyroidism should raise suspicion for hereditary PHPT. In a series of 269 patients, six
had decreases in IOPTH values that were consistent with a cure but later recurred [101]. Three of
the six patients had germline mutations in the MEN gene (MEN1), and two had mutations in the
RET proto-oncogene (MEN2). (See "Multiple endocrine neoplasia type 1: Clinical manifestations
and diagnosis" and "Clinical manifestations and diagnosis of multiple endocrine neoplasia type
2".)
Radioguided parathyroidectomy — In the past, a radioguided approach was

advocated by some to serve as an adjunct to parathyroid exploration. The technique involves
intravenous administration of technetium-99m-labeled sestamibi approximately two hours
preoperatively [102,103]. Using sestamibi uptake as an indirect measure of parathyroid gland
hyperfunction, the surgeon uses a handheld gamma probe in conjunction with preoperative
imaging results to focus the incision over the site of greatest radioactivity. Once the suspected
offending gland or glands are removed, intraoperative PTH monitoring is typically used to
attempt to confirm adequate parathyroidectomy. The gamma probe is also used to survey the
surgical bed (background radioactivity). An ex vivo radioactivity count of >20 percent of the
background radioactivity is a suggested threshold for completion of the exploration.
Use of the gamma probe alone, however, may not reliably ensure operative cure. The probe
detects sestamibi uptake as a surrogate for hyperfunctioning parathyroid tissue, a method that
is unreliable for definitively excluding multigland disease [96,104,105]. Furthermore, thyroid
nodules often retain isotope, which can potentially lead to false positive results and resection of
healthy thyroid tissue. Additionally, concentration of radioactivity in the heart can lead to
misinterpretations if the probe is angled below the clavicle. Finally, the timing and dosing
requirements for isotope injection can cause delays in the operating room schedule.
Anesthesia — Focused parathyroidectomy can be performed under general anesthesia

or superficial cervical plexus block anesthesia with monitored conscious sedation. The latter is
most appropriate when a single gland has been well localized and the procedure is expected to
have a short duration [106,107]. Compared with general anesthesia, cervical plexus block may
reduce postoperative pain, nausea, and vomiting [108]. However, cervical plexus block
anesthesia should be avoided in obese or claustrophobic patients. (See "Anesthesia for patients
with thyroid disease and for patients who undergo thyroid or parathyroid surgery", section on
'Choice of anesthetic technique'.)
In a report of 441 patients undergoing focused parathyroidectomy under cervical plexus block
anesthesia, 10 percent required conversion to general anesthesia [108]. Reasons for conversion
included concomitant thyroid disease (34 percent), multigland parathyroid hyperplasia (failure of
PTH levels to drop, 32 percent), technical considerations (17 percent), patient discomfort (11
percent), intraoperative diagnosis of parathyroid carcinoma (4 percent), and a purported
reaction to locally administered lidocaine with seizure (2 percent). (See "Allergic reactions to local
anesthetics".)
Incision — A 2 cm incision is made on the anterior aspect of the mid-neck. Guided by

preoperative imaging, the incision may be lateralized to the side of the predicted parathyroid
adenoma. If IOPTH monitoring is used, a pre-excision baseline PTH level is obtained just prior to
the incision. (See 'Intraoperative parathyroid hormone monitoring' above.)
Dissection — The platysma is divided transversely and the median raphe longitudinally.
The strap muscles on the side of dissection are elevated off the thyroid lobe ipsilateral to the
suspected adenoma localized by preoperative imaging studies.
If imaging predicts a laterally or posteriorly located gland, a "backdoor" initial approach may be
useful. In this setting, the lateral border of the strap muscles is separated from the medial
border of the sternocleidomastoid muscle, exposing the lateral edge of the thyroid gland as the
plane where parathyroid exploration begins.
Exploration — (See 'Exploration' above.)

First gland — Following resection of the first enlarged and presumable localized gland,
either blood draws are sent for IOPTH assay after 5 and 10 minutes, or exploration continues if
bilateral exploration is planned. If the intraoperative PTH level does not drop appropriately after
excising the first gland, the diagnosis of multigland disease is made, and multigland resection
should be performed [2]. Procedures that begin as a focused parathyroid exploration should be
promptly converted to a bilateral exploration, and all four glands should be inspected, prior to
excision of additional parathyroid tissue. (See 'Multigland disease' above.)
Closure — (See 'Closure' above.)

Documentation — (See 'Documentation' above.)
PERCUTANEOUS PARATHYROID
ABLATION — In centers with the appropriate expertise, percutaneous
parathyroid ablation is an acceptable treatment for patients who need treatment for primary
hyperparathyroidism (PHPT) but are not surgical candidates or have an inoperable mediastinal
gland [109-111]. Percutaneous parathyroid ablation is discussed in the setting of complex
recurrent PHPT after a failed parathyroidectomy in an inoperable patient.
The parathyroid gland can be percutaneously ablated angiographically or by ethanol injection

under ultrasound guidance. Success rates of 66 percent at up to four years have been reported
for angiographic ablation [109]. Ethanol ablation was successful in restoring eucalcemia in 82
percent of patients who failed subtotal parathyroidectomy for multiple neoplasia syndrome type
1-associated hyperparathyroidism [112]. However, recurrent hypercalcemia requiring repeat
treatments is common after percutaneous ablation.
POSTOPERATIVE CARE — After parathyroid surgery, patients

with reoperation, extensive exploration, subtotal resection, profound vitamin D deficiency, or a
lack of social support should be admitted for overnight observation. Other patients may be
discharged following "outpatient" parathyroid surgery at the surgeon's discretion [2]. However,
all patients must be examined to exclude bleeding and confirm that esophageal swallowing is
normal, pain is controlled, and no allergic reaction to medication has occurred prior to hospital
discharge. An exam is recommended at a minimum of four to six hours after the procedure.
Evidence of compressive hematoma should prompt emergency decompression. (See
"Thyroidectomy", section on 'Hematoma'.)
Patients can remove the surgical dressing and shower on the day following the operation. Pain is
usually modest and controllable with mild analgesics such as acetaminophen. In general, opiate
narcotics should be avoided. Oversedation brought on by narcotics can potentiate an airway
emergency if there is a clinically significant cervical hematoma.
At one to two weeks postoperatively, patients should be seen in the office by the surgical team
to inspect the wound, review pathology, and obtain a baseline postoperative biochemical
assessment.
At six months postoperatively, patients should have a repeat clinic visit with biochemical
assessment. For most patients, cure after parathyroidectomy is defined as the reestablishment
of normal calcium homeostasis lasting a minimum of six months. For patients with
normocalcemic PHPT, the PTH level must also normalize at six months after surgery to indicate
cure [2,113].
At six months to one year following documented cure (ie, 12 to 18 months following
parathyroidectomy), we also suggest a follow-up visit along with a repeat biochemical
assessment and a comparative bone mineral density study [2,114]. (See "Overview of dual-
energy x-ray absorptiometry".)
COMPLICATIONS — Complications following parathyroidectomy are

uncommon. However, the patient should be counseled about them preoperatively, and the
surgeon should be knowledgeable about their presentation and management.
Operative failure — Failure to achieve durable cure of hypercalcemia is the most

common complication of parathyroid surgery (reported at rates of 1 to 5 percent). (See
'Outcomes' below.)
Symptomatic hematoma — The incidence of symptomatic hematoma

following neck exploration is 0.3 to 1 percent [115]. Symptoms include anxiety, respiratory
distress, dysphagia, fullness, and persistent or increasing pain. On examination, a large anterior
cervical mass is often visible. Although rare, this complication can result in life-threatening
airway compromise. Cervical hematoma results in venous congestion of airway structures,
creating significant laryngeal edema and subsequent airway compromise. In addition,
oropharyngeal swelling creates a narrow window for reintubation. With rare exceptions, the
presence of hematoma indicates urgent surgical evaluation and treatment. Early recognition
and immediate intervention are crucial to minimizing mortality [115,116]. (See "Thyroidectomy",
section on 'Complications'.)
Postoperative hypocalcemia — Hypocalcemia is an important

potential complication of parathyroid exploration. After a focused parathyroid exploration, low
serum calcium may be the result of suppression of the other glands, which require the stimulus
of hypocalcemia to resume function. If a bilateral exploration or prior contralateral exploration
has taken place, the hypocalcemia may be caused by inadvertent injury to or loss of function of
the remaining parathyroid glands. Thus, it is prudent to confirm function of the residual
parathyroid tissue with a parathyroid hormone (PTH) assessment. The classic calcium nadir
occurs within the first 24 to 48 hours after a parathyroidectomy, and a serum PTH value can be
obtained on the first postoperative day prior to discharge. Preoperative assessment of vitamin D
status, along with repletion of deficiency if present, is safe [117] and is routine in many high-
volume practices today.
Mild hypocalcemia — Mild postoperative hypocalcemia may be due to bone

hunger or functional hypoparathyroidism resulting from suppression of the remaining normal
parathyroid tissue. Symptoms, including perioral or acral paresthesias and anxiety, can be
exacerbated by hyperventilation. Mild hypocalcemia generally responds well to a short course of
oral calcium supplementation, starting with 1500 to 2000 mg of elemental calcium daily in
divided doses, given as calcium carbonate or calcium citrate. (See "Hypoparathyroidism", section
on 'Postsurgical hypoparathyroidism'.)
Transient postoperative hypocalcemia is more common in patients with severe preoperative

hypercalcemia and in those with chronic vitamin D deficiency (<15 ng/mL). For this reason,
preoperative ergocalciferol (vitamin D2, 1000 IU daily or more depending on vitamin D level) is
desirable in vitamin D-deficient patients whose urinary calcium levels are not elevated. If
hypercalciuria limits the ability to replete vitamin D preoperatively, it is important to provide
adequate calcium and ergocalciferol after surgical correction of primary hyperparathyroidism
(PHPT). (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment",
section on 'Coexisting primary hyperparathyroidism'.)
Severe hypocalcemia — Symptoms of severe hypocalcemia include tetany,

electrocardiogram (EKG) changes, papilledema, and seizures. A patient with severe, symptomatic
postoperative hypocalcemia may require intravenous and oral calcium supplementation as well
as correction of concomitant hypomagnesemia [118]. (See "Clinical manifestations of
hypocalcemia" and "Treatment of hypocalcemia", section on 'Intravenous calcium dosing'.)
Appropriate treatment for severe hypocalcemia also depends in part on the phosphate and PTH
levels:
●Hypophosphatemia – If prolonged hypocalcemia is accompanied by low or normal phosphate

levels and normal or high PTH levels, hungry bone syndrome is diagnosed. Hungry bone
syndrome is caused by rapid deposition of serum calcium into demineralized bone following a
drop in PTH. Treatment for hungry bone syndrome is discussed elsewhere. (See "Hungry bone
syndrome following parathyroidectomy in end-stage kidney disease patients".)
●Hyperphosphatemia – If hypocalcemia is accompanied by hyperphosphatemia and low PTH

levels, hypoparathyroidism is diagnosed, requiring treatment with calcitriol. (See "Etiology of
hypocalcemia in adults" and "Hypoparathyroidism", section on 'Management'.)
Permanent hypoparathyroidism — Permanent hypoparathyroidism may

occur with resection or devascularization of normal parathyroid glands, especially in patients
who have had previous neck surgeries. It may also occur following a subtotal parathyroidectomy
if the parathyroid remnant is not viable.
After an apparently successful parathyroidectomy, calcium intake should follow the Institute of
Medicine (IOM) Dietary Reference Intakes, and patients who are vitamin D deficient should
receive vitamin D supplementation [2]. If calcitriol and calcium supplementation cannot be
tapered off over several months following surgery, the hypoparathyroidism may be permanent.
An undetectable or markedly low serum PTH level when serum calcium level is low confirms the
diagnosis and indicates the permanent need for treatment. (See "Hypoparathyroidism", section
on 'Chronic hypoparathyroidism'.)
Wound infection — Parathyroid surgery is a clean procedure in a well-

vascularized area; wound infection is a rare complication. Redness and inflammation at the
incision are more likely to be caused by skin reactions to tape or suture materials.
Recurrent laryngeal nerve injury — Recurrent laryngeal nerve

(RLN) injury is a rare complication that occurs in <1 percent of initial operations in the hands of
experienced parathyroid surgeons. Reoperations are associated with a higher risk of RLN
injuries due to scarring and distorted anatomy.
To minimize the risk of RLN injury, the surgeon should review the patient's prior operative and
pathology reports to gain information regarding the extent of prior dissection. Preoperative
laryngoscopy is also recommended in the reoperative setting to assess any preexisting RLN
compromise (see 'Preoperative evaluation and management' above). Intraoperative
neuromonitoring can be helpful in high-risk reoperative cases but should augment, rather than
circumvent, the need for meticulous surgical techniques, including intraoperative visual
identification of the RLN. (See "Thyroidectomy", section on 'Intraoperative nerve monitoring'.)
The diagnosis and treatment of RLN injuries are discussed separately. (See "Thyroidectomy",
section on 'Nerve injury/vocal cord paresis or paralysis'.)
Hyperthyroidism — Hyperthyroidism is an underappreciated consequence of

thyroid gland manipulation (also referred to as palpation thyroiditis) at the time of parathyroid
surgery [24,119]. Biochemical evidence and symptoms (eg, mild thyrotoxicosis) of
hyperthyroidism was found in 31 to 43 percent and 15 to 27 percent of patients, respectively
[24]. Thus, patients with symptoms of hyperthyroidism should be monitored for biochemical or
clinical evidence of hyperthyroidism in the early postoperative period after parathyroidectomy.
Those with symptoms can be treated with thionamides and/or beta blockers as indicated. In
general, the hyperthyroidism is transient and self-limited, with thyroid function studies
normalizing within a few weeks to months. (See "Overview of the clinical manifestations of
hyperthyroidism in adults" and "Thionamides in the treatment of Graves' disease" and "Beta
blockers in the treatment of hyperthyroidism".)
OUTCOMES — The surgical cure rate for primary hyperparathyroidism (PHPT)

should be ≥95 percent [30,40,120]. Operative management is more effective and less costly than
either long-term observation or pharmacologic therapy [2]. However, the overall survival of
patients treated successfully for PHPT is uncertain; increased mortality due to persistent
cardiovascular disease after surgical cure of PHPT has been reported [121]. (See "Primary
hyperparathyroidism: Clinical manifestations".)
Persistent or recurrent disease may be the result of surgeon inexperience, supernumerary

glands, or unrecognized multigland disease. Reoperation is technically challenging with higher
rates of morbidity [122-124] and higher incidences of recurrent laryngeal nerve (RLN) injury and
permanent hypoparathyroidism as well as higher rates of failure to cure [122-124]. Thus,
indications for reoperations are more stringent than for initial surgery. (See 'Indications' above.)
Patients with persistent or recurrent PHPT should be evaluated by an experienced parathyroid

surgeon for possible reoperation. The evaluation should include confirmation of biochemical
diagnosis, assessment of indications for surgery, review of prior records if available, and
evaluation of RLN function. Some surgeons prefer to have two concomitant, concordant imaging
studies before performing reoperation. Precise description of gland location using a
standardized nomenclature system is particularly useful for reoperative surgery [125]. A
targeted approach based on preoperative imaging should be used for reoperations [2].
In the majority of reoperations for persistent or recurrent PHPT, the hyperfunctional parathyroid
gland is identified in a usual and expected anatomic location, such as the deep
tracheoesophageal groove or superior portion of the cervical thymus [126]. Ectopic parathyroid
glands, such as undescended glands or those deep within the mediastinum, are uncommon.
The cure rate of reoperations may be by the use of intraoperative parathyroid hormone
monitoring to confirm excision of all hyperfunctioning tissue and, in some cases, to guide
laterality of dissection [127]. (See 'Intraoperative assessment' above.)
Although surgical removal of the hyperfunctional parathyroid tissue is the only definitive therapy
for persistent or recurrent PHPT, patients who refuse surgery or have a parathyroid gland that
cannot be found may be managed medically [128]. (See "Primary hyperparathyroidism:
Management".)
SOCIETY GUIDELINE LINKS — Links to society and

government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Parathyroid surgery" and "Society guideline
links: Primary hyperparathyroidism".)
SUMMARY AND RECOMMENDATIONS

●Primary hyperparathyroidism (PHPT) is typically diagnosed when hypercalcemia is detected
incidentally on routine biochemical screening tests. Clinical manifestations of PHPT include
polydipsia and polyuria, nephrolithiasis, nephrocalcinosis, osteoporosis, fragility fractures,
vertebral compression fractures, pancreatitis, peptic ulcer disease, gastroesophageal reflux,
fatigue, depression, and significant neurocognitive dysfunction. Although some patients are
completely asymptomatic, many have nonspecific and often subtle symptoms, such as fatigue,
depression, irritability, anxiety, anorexia, difficulty with concentration, or memory impairment.
(See 'Introduction' above and 'Indications' above.)
●Parathyroidectomy is the definitive therapy for PHPT and is indicated for all patients with
symptomatic PHPT, patients with familial PHPT (multiple endocrine neoplasia [MEN] type 1 and
2A, or familial hyperparathyroidism), and patients with asymptomatic disease who have
decreased renal function (glomerular filtration rates <60 mL/minute), hypercalciuria (24 hour
urine calcium level >400 mg/dL), osteoporosis, serum calcium >1 mg/dL above normal, age <50
years, or who prefer surgery to observation. Parathyroid exploration is also indicated for
patients with parathyroid cancer or parathyroid crisis and for selected patients with persistent or
recurrent PHPT after a previous parathyroid surgery. (See 'Indications' above.)
●Contralateral recurrent laryngeal nerve (RLN) injury and symptomatic cervical disc disease are
relative contraindications to parathyroidectomy. Patients with familial hypocalciuric
hypercalcemia do not have a primary parathyroid disorder and should not undergo
parathyroidectomy. (See 'Contraindications' above.)
●For selected patients who have unilateral pathology as localized by preoperative imaging, no
concomitant thyroid disease, and no family history of MEN, we suggest focused
parathyroidectomy, rather than bilateral cervical exploration (Grade 2B). The success of focused
parathyroidectomy is dependent upon both preoperative localization studies that limit the
operative field to the region where a presumed single adenoma is and the use of intraoperative
parathyroid hormone (PTH) monitoring to confirm that no other hyperfunctioning gland
remains in situ. (See 'Choice of procedure' above and 'Focused parathyroid exploration' above.)
●Initial bilateral neck exploration should still be performed when a single hyperfunctioning
gland cannot be identified on preoperative imaging, when a focused approach fails, when the
preoperative or intraoperative findings suggest multigland disease, for most forms of familial
diseases, and when there is concomitant thyroid pathology (see 'Choice of procedure' above and
'Bilateral parathyroid exploration' above). Intraoperative parathyroid hormone monitoring is
necessary in virtually all cases.
●For most patients, cure after parathyroidectomy is defined as the reestablishment of normal
calcium homeostasis lasting a minimum of six months. For patients with normocalcemic PHPT,
the PTH level must also normalize at six months after surgery to indicate cure. In experienced
hands, surgical cure is achieved in ≥95 percent of initial parathyroidectomies; the recurrence
rate is higher with reoperations. During exploration for primary hyperparathyroidism, expert
understanding of the embryology and anatomy of the parathyroid glands is essential to achieve
surgical cure. A missed parathyroid adenoma is the most common cause for a failed initial
parathyroid operation and persistent hyperparathyroidism. (See 'Missing gland' above and
'Outcomes' above.)
●Major complications after parathyroidectomy include failure to achieve durable cure of

hypercalcemia, hematoma with airway compromise, hypoparathyroidism, and RLN injury. (See
'Complications' above.)
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Topic 15039 Version 25.0
References
1 : Clinical practice. Asymptomatic primary hyperparathyroidism.
2 : The American Association of Endocrine Surgeons Guidelines for Definitive Management of

Primary Hyperparathyroidism.
3 : Asymptomatic hyperparathyroidism: a medical misnomer?
4 : Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international

workshop.
5 : What predicts adverse outcomes in untreated primary hyperparathyroidism? The Parathyroid

Epidemiology and Audit Research Study (PEARS).
6 : Guidelines for the management of asymptomatic primary hyperparathyroidism: summary

statement from the third international workshop.
7 : Management of patients with persistent or recurrent primary hyperparathyroidism.
8 : Reoperations for primary hyperparathyroidism--improvement of outcome over two decades.
9 : Value of preoperative ultrasound-guided fine-needle aspiration for localization in Tc-99m MIBI-

negative primary hyperparathyroidism patients.
10 : Parathyroid hormone assay in fine-needle aspirate is useful in differentiating inadvertently

sampled parathyroid tissue from thyroid lesions.
11 : Normocalcemic primary hyperparathyroidism.
12 : Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a
perspective for the 21st century.
13 : Primary hyperparathyroidism revisited in menopausal women with serum calcium in the upper
normal range at population-based screening 8 years ago.
14 : Parathyroid cyst: an uncommon cause of a palpable neck mass and hypercalcemia.
15 : Cystic parathyroid lesions: functional and nonfunctional parathyroid cysts.
16 : Long-term results of parathyroidectomy for hypercalcemic crisis.
17 : Accuracy and definitive interpretation of preoperative technetium 99m sestamibi imaging based
on the discipline of the reader.
18 : Effect of a 19-item surgical safety checklist during urgent operations in a global patient
population.
19 : Hyperparathyroidism among atomic bomb survivors in Hiroshima.
20 : Chronic left ventricular thrombi.
21 : Lithium-associated hyperparathyroidism and hypercalcaemia: a case-control cross-sectional

study.
22 : Parathyroid adenomas versus four-gland hyperplasia as the cause of primary

hyperparathyroidism in patients with prolonged lithium therapy.
23 : Identification of multiple endocrine neoplasia type 1 in patients with apparent sporadic primary
hyperparathyroidism.
24 : Hyperthyroidism after parathyroid exploration.
25 : Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings

of the Fourth International Workshop.
26 : Minimizing cost and maximizing success in the preoperative localization strategy for primary
27 : The usefulness of high pre-operative levels of serum type I collagen bone markers for the
prediction of changes in bone mineral density after parathyroidectomy.
28 : Changes in bone turnover markers in primary hyperparathyroidism and response to surgery.
29 : Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a

perspective for the 21st century.
30 : Six hundred fifty-six consecutive explorations for primary hyperparathyroidism.
31 : Bilateral Neck Exploration for Sporadic Primary Hyperparathyroidism: Use Patterns in 5,597
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32 : Long-term results of surgery for lithium-associated hyperparathyroidism.
33 : Appropriate surgical treatment of lithium-associated hyperparathyroidism.
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38 : Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective

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40 : Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up
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41 : Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical

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42 : Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a

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43 : Focused versus conventional parathyroidectomy for primary hyperparathyroidism: a

prospective, randomized, blinded trial.
44 : Operation for primary hyperparathyroidism: the new versus the old order. A randomised
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46 : Focused Versus Bilateral Parathyroid Exploration for Primary Hyperparathyroidism: A

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47 : Endoscopic parathyroid surgery: results of 365 consecutive procedures.
48 : Results of video-assisted parathyroidectomy: single institution's six-year experience.
49 : Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid
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50 : Surgical treatment of primary hyperparathyroidism.
51 : Totally endoscopic lateral parathyroidectomy: prospective evaluation of 200 patients. ESES

2010 Vienna presentation.
52 : Endoscopic parathyroidectomy in primary hyperparathyroidism.
53 : Recurrent laryngeal nerve monitoring: state of the art, ethical and legal issues.
54 : Antibiotic prophylaxis in thyroid surgery: a preliminary multicentric Italian experience.
55 : Antibiotic prophylaxis in clean surgery: clean non-implant wounds.
56 : Factors influencing antibiotic prophylaxis for surgical site infection prevention in general
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57 : Surgical site infections and the surgical care improvement project (SCIP): evolution of national
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58 : Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical
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59 : Improving antibiotic stewardship: order set implementation to improve prophylactic
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60 : Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery.
61 : Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical

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62 : Profile of a clinical practice: Thresholds for surgery and surgical outcomes for patients with
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63 : A novel nomenclature to classify parathyroid adenomas.
64 : Recurrent hyperparathyroidism secondary to parathyromatosis: clinical and imaging findings.
65 : Parathyromatosis: a rare yet important cause of persistent or recurrent hyperparathyroidism.
66 : The small abnormal parathyroid gland is increasingly common and heralds operative
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67 : Evaluation of Parathyroidectomy for Secondary and Tertiary Hyperparathyroidism by the

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68 : To assess the effects of parathyroidectomy (TPTX versus TPTX+AT) for Secondary

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71 : A new approach to parathyroidectomy.
72 : Reoperation for primary hyperparathyroidism: tips and tricks.
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89 : Parathyroid cancer.
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92 : Focus on parathyroid carcinoma.
93 : Parathyroid cancer: outcome analysis of 16 patients treated at the Princess Margaret Hospital.
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on long-term follow-up.

Parathyroid Exploration For Primary Hyperparathyroidism - Uptodate 2022

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Why What's Patient Calculators Drug

Parathyroid exploration for primary

Angelica Silva Figueroa, MD

INTRODUCTION — Primary hyperparathyroidism (PHPT) is most

INDICATIONS — Once a diagnosis of primary hyperparathyroidism (PHPT)

Symptomatic PHPT — Surgical intervention is indicated for all patients with

●Polydipsia and polyuria.

●Hypercalcuria (24 hour urine calcium level >400 mg/dL).

●Impaired renal function (glomerular filtration rate [GFR] <60 mL/minute).

●Pancreatitis, peptic ulcer disease, or gastroesophageal reflux.

●Neurocognitive dysfunction or neuropsychiatric symptoms attributable to PHPT.

Asymptomatic PHPT — Asymptomatic patients have a biochemical diagnosis

●Age <50 years.

●Serum calcium level >1 mg/dL above normal range.

●Silent nephrolithiasis or nephrocalcinosis.

●Patients who are unable or unwilling to comply with surveillance protocols.

Persistent or recurrent PHPT — After initial parathyroidectomy,

●Serum calcium level >12 mg/dL

●A 30 percent decrease in renal creatinine clearance

Familial PHPT — Hereditary forms of PHPT occur either as a part of a multiple

Normocalcemic PHPT — Normocalcemic PHPT is an increasingly

Parathyroid cancer — Parathyroid cancer is a rare cause of PHPT. It may be

Parathyroid cyst — Parathyroid cysts are uncommon but can cause

Parathyroid crisis — Parathyroid crisis is characterized by severe hypercalcemia

Emergency parathyroidectomy is indicated in patients with a parathyroid crisis. In a report of 43

CONTRAINDICATIONS — Relative and absolute

●Symptomatic cervical disc disease is a relative contraindication to neck exploration because of

●Familial hypocalciuric hypercalcemia (FHH) is an absolute contraindication to parathyroid

PREOPERATIVE EVALUATION AND

Pertinent clinical history includes a family history of primary hyperparathyroidism (PHPT),

Imaging should focus on evaluation of potential end-organ damages caused or exacerbated by

Patients undergoing a focused parathyroidectomy for PHPT should undergo a preoperative

CHOICE OF PROCEDURE — Once the decision to perform a

exploration or a more focused parathyroidectomy is appropriate. The goal of parathyroid

Approximately 15 percent of patients with primary hyperparathyroidism (PHPT) have hyperplasia

Bilateral parathyroid exploration — Bilateral parathyroid

Bilateral parathyroid exploration is the preferred operative strategy when intraoperative

●When the patient has lithium-associated hyperparathyroidism. Lithium-associated PHPT has a

Focused parathyroid exploration — Focused parathyroidectomy

When performed with IOPTH monitoring, focused parathyroidectomy results in excellent

SURGEON'S SAFETY CHECKLIST FOR

●Parathyroid hormone monitoring – If intraoperative parathyroid hormone (PTH) monitoring

●Antibiotics – Parathyroid surgery is a clean procedure in a well-vascularized area; thus,

●Anticoagulation – Most parathyroidectomies are elective. Thus, any bleeding diatheses,

●Deep venous thrombosis prophylaxis – Patients undergoing general anesthesia should

SURGICAL MANAGEMENT — The challenges of

Parathyroidectomy is an operation that is well documented to exhibit high-volume expertise (ie,

As follows, the techniques of bilateral parathyroid exploration and focused parathyroidectomy

Bilateral parathyroid exploration

Positioning — The patient is positioned on the operating table in the semi-Fowler

Incision — If a bilateral exploration is planned, a 3 to 5 cm transverse incision is usually

First gland — Once identified, a first enlarged parathyroid gland is dissected

Multigland disease — If the second parathyroid gland ipsilateral to the first is

Missing supernumerary gland — Most supernumerary parathyroid glands are

Compromised gland — Although only one normal parathyroid gland is necessary

To perform parathyroid autotransplantation, a small pocket is created in the designated muscle,

Alternatively, cryopreservation is available at some centers and is useful in some patients to

For patients with MEN type 2A-associated recurrent hyperparathyroidism, a complete

Parathyroid carcinoma — Parathyroid carcinoma is a rare cause of primary

●A solitary tumor greater than 3 cm in diameter [77].

●A firm, irregular, lobulated mass [78].