How is a directed parathyroidectomy performed for the treatment of primary hyperparathyroidism?

Updated: Dec 24, 2020
  • Author: Lawrence Kim, MD, FACS, FACE; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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In many respects, the operative technique is similar to that described above for a complete parathyroid exploration. Differences are noted below.

Adequate imaging of the abnormal gland prior to surgery is essential. In addition, arrangements for intraoperative measurement of parathyroid hormone should be confirmed. [2] A line for sampling of peripheral venous blood should be established. Often, the distal saphenous vein provides the most convenient access.

Some surgeons modify the location of the incision based on the preoperative location of the adenoma. This author prefers a small incision (ie, ~2 cm) in the standard location for a collar incision. This incision can be readily extended should extensive exploration prove necessary.

A baseline parathyroid hormone level is drawn immediately prior to skin incision. Following identification and dissection of the adenoma, a preexcision level is drawn. Manipulation of the gland occasionally causes significant increases, sometimes of more than 10-fold, in the parathyroid hormone level. Following excision of the gland, parathyroid hormone levels are drawn at 5 minutes and 10 minutes postexcision. Criteria for adequate excision are either a 50% drop in parathyroid hormone from the baseline level to the 10-minute postexcision level or a 50% drop in parathyroid hormone from the preexcision level at 10 minutes and a postexcision level below the baseline level. [38]

The incision may be closed while the last parathyroid hormone levels are being processed, but the patient should remain under anesthesia, and the sterile field maintained until the parathyroid hormone assay results are known.

If a directed parathyroidectomy is performed successfully, most of these patients may be safely discharged the day of surgery.

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