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288
C. G. Nair
References
1. Sandström IV. On a new gland in man and several mammals—glandulae parathyroideae.
Upsala Läk Förenings Förh. 1879–1880;15:441–71.
2. Owen R.On the anatomy of the Indian rhinoceros (Rh. unicornis, L). Trans Zool Soc Lond.
1862;4:31–58.
3. Halsted WS, Evans HM.The parathyroid glandules. Their blood supply and their preservation
in operation upon the thyroid gland. Ann Surg. 1907;46(4):489–506.
4. Salvesen HA.Studies of the physiology of the parathyroids. Acta Med Scand. 1923;(Suppl.
6):1–159.
5. MacCallum WJ, Voegtlin C.On the relation of the parathyroid to calcium metabolism and the
nature of tetany. Bull Johns Hopkins Hosp. 1908;19:91–2.
6. MacCallum WJ, Davidson CF.Further notes on the function of the parathyroid glands. Med
News. 1905;86:625–33.
7. von Recklinghausen FD (1891) Festschrift fur Rudolf Virchow Reimer. Berlin. Die bröse
oder deformierende Ostitis, die Osteomalacie und die osteoplastische Karzinose in ihren
gegenseitigen Beziehungen; pp.1–89.
8. Erdheim J.Uber die Dentinverkalkung in Nagezahn bei der Epithelkörerchen transplantation.
Frankfurt Z Path. 1911;7:295–342.
9. Schlagenhaufer F.Zwei Fälle von Parathyroideatumoren. Wien Klin Wschr. 1915;28:1362.
10. Collip JB, Leitch DB. A case of tetany treated with parathyrin. Can Med Assoc
J. 1925;15(1):59–60.
11. Rasmussen H, Craig LC. The parathyroid polypeptides. Recent Prog Horm Res.
1962;18:269–95.
12. Dorairajan N.Pradeep PV Vignette hyperparathyroidism: glimpse into its history. Int Surg.
2014;99(5):528–33.
13. Delbridge LW, Palazzo FF.First parathyroid surgeon: Sir John Bland-Sutton and the parathyroids. ANZ J Surg. 2007;77:1058–61.
14. Berson SA, Yalow RS, Aurbach GD, Potts JT Jr. Immunoassay of bovine and human parathyroid hormone. Proc Natl Acad Sci U S A. 1963;49:613–7.
15. Carter AB, Howanitz PJ. Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature. Arch Pathol Lab Med.
2003;127(11):1424–42.
16. Brasier AR, Wang C, Nussbaum SR.Recovery of parathyroid hormone secretion after parathyroid adenomectomy. J Clin Endocrinol Metab. 1988;66:495–500.
17. Nussbaum SR, Zahradnik RJ, Lavigne JR, Brennan GL, Nozawa-Ung K, Kim LY, Keutmann
HT, Wang CA, Potts JT Jr, Segre GV, Au Cole DE, Webb S, Chan PC. Clin Chem.
1987;33(8):1364–7.
18. Cole DE, Webb S, Chan PC.Update on parathyroid hormone: new tests and new challenges for
external quality assessment. Clin Biochem. 2007;40(9–10):585–90.
19. Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA.Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. Surgery.
1988;104(6):1121–7.
20. Irvin GL 3rd, Deriso GT 3rd. A new, practical intraoperative parathyroid hormone assay. Am
J Surg. 1994;168(5):466–8.
21. Irvin GL III, Carneiro DM, Solorzano CC.Progress in the operative management of sporadic
primary hyperparathyroidism over 34 years. Ann Surg. 2004;239(5):704–11.
22. Irvin GL III, Solorzano CC, Carneiro DM.Quick intraoperative parathyroid hormone assay:
surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg. 2004;28:1287–92.
23. Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, Milas M.Predicting
the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi,
and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248(3):420–8.
20 Surgical Treatment ofHyperparathyroidism: AnOverview
24. Riss P, Kaczirek K, Heinz G, Biglmayer C, Niederle B.A “dened baseline” in PTH monitoring
increases surgical success in patients with multiple gland disease. Surgery. 2007;142:398–404.
25. Lombardi CP, Rafaelli M, Traini E, Di Stasio E, Carrozza C, De Crea C, Zuppi C, Bellantone
R.Intraoperative PTH monitoring during parathyroidectomy: the need for stricter criteria to
detect multiglandular disease. Langenbecks Arch Surg. 2008;393:639–45.
26. Castleman B, Mallory TB.The pathology of the parathyroid glands in hyperparathyroidism: a
study of 25 cases. Am J Pathol. 1935;11(1):1–72.17.
27. van Heerden JA, Grant CS. Surgical treatment of primary hyperparathyroidism: an institutional perspective. World J Surg. 1991;15(6):688–92.
28. Singh Ospina NM, Rodriguez-Gutierrez R, Maraka S, etal. Outcomes of parathyroidectomy
in patients with primary hyperparathyroidism: a systematic review and meta-analysis. World J
Surg. 2016;40(10):2359–77.
29. Doppman JL. Reoperative parathyroid surgery; localization procedures. Prog Surg.
1986;18:117–32.
30. Coakley AJ, Kettle AG, Wells CP, O’Doherty MJ, Collins RE. 99Tcm Sestamibi—a new agent
for parathyroid imaging. Nucl Med Commun. 1989;10:791–4.
31. Young AE, Gaunt JI, Croft DN, Collins RE, Wells CP, Coakley AJ. Location of parathyroid adenomas by thallium-201 and technetium-99m subtraction scanning. Br Med
J. 1983;286:1384–6.
32. Carpentier A, Jeannotte S, Verrault J, etal. Preoperative localization of parathyroid lesions in
hyperparathyroidism: relationship between technetium-99m-MIBI and oxyphil cell count. J
Nucl Med. 1998;39:1441–4. 2007; 48:1084
33. Torregrosa F, Fuster JV, D.Biological factors inuencing parathyroid localization. Nucl Med
Commun. 2003;24(2):121–1241089.
34. Mitchell BK, Merrell RC, Kinder BK.Localization studies in patients with hyperparathyroidism. Endocr Surg. 1995;75:483–98.
35. Udelsman R, Donovan PI, Sokoll LJ.One hundred consecutive minimally invasive parathyroid
explorations. Ann Surg. 2000;232(3):331–9.
36. Scott NA, Reeve TS, Parkyn RF, etal. Systematic review of minimally invasive parathyroidectomy: update and re-appraisal. 2001. In: Database of abstracts of reviews of effects (DARE):
quality-assessed reviews. York (UK): Centre for Reviews and Dissemination (UK); 1995.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK68828.
37. Selverstone B, Sweet WH, Robinson CV. The clinical use of radioactive phosphorus in the
surgery of brain tumors. Ann Surg. 1949;130(4):643–51.
38. Harris CC, Bigelow RR, Francis JE, Kelly GG, Bell PR.A Csi(Ti)-crystal surgical scintillation
probe. Nucleonics. 1956;14:102–8.
39. Murphy C, Norman J. The 20% rule: a simple, instantaneous radioactivity measurement
denes cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery. 1999;126(6):1023–9.
40. Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative
nuclear mapping. Surgery. 1997;122:998–1003.
41. Flynn MB, Bumpous JM, Schill K, K.M.McMasters minimally invasive radioguided parathyroidectomy. J Am Coll Surg. 2000;191:24–31.
42. Rubello D, Mariani G, Pelizzo MR, Italian Study Group of Radioguided Surgery and
ImmunoScintigraphy. Minimally invasive radioguided parathyroidectomy on a group of 452
primary hyperparathyroid patients: renement of preoperative imaging and intraoperative procedure. Nuklearmedizin. 2007;46:85–92.
43. Taillefer R, Boucher Y, Potvin C, Lambert R.Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with
Tc-99m sestamibi (double phase study). J Nucl Med. 1992;33:1801–7.
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Parathyroidectomy: Surgical Techniques
21
C.GopalakrishnanNair andRijuRamachandran
21.1 Preoperative Workup andPreparation
The majority of Indian patients are symptomatic unlike those frequently encountered in North American and European countries. Hypercalcemia used to be severe
among symptomatic patients. Mild hypercalcemia (<12 mg/dl) does not require
active correction before surgery. Hypercalcemia above 12mg/dl requires correction
before surgery. Volume expansion by administration of normal saline 200–300ml/h
(4–6L in 24h) brings down the calcium and is the rst line of treatment. The volume expansion should be carefully monitored in the elderly and in those with cardiac and renal dysfunction. Intravenous bisphosphonates (Zoledronic acid 4mg
slowly over 20min, or Pamidronate 30–90mg at 20mg per h is effective in bringing
down the serum calcium level but usually by 3–4 days. The moderate (12–14mg/dl)
and severe hypercalcemia (>14mg/dl) require close observation in high dependency wards. Subcutaneous calcitonin (4–8 units/kg body weight) administered
twice daily or even 6th hourly is effective in controlling hypercalcemia. Calcitonin
reduces the serum calcium concentration by increasing renal calcium excretion and,
more importantly, by decreasing bone resorption via interference with osteoclast
function. Calcitonin brings down the calcium level by 1–2mg in 4 h and is safe
along with intravenous saline. But the effect is short-lived and limited to 48h indicating the development of tachyphylaxis, perhaps due to receptor downregulation.
More sustained but slow control of hypercalcemia is obtained by intravenous
administration of Bisphosphonates. Zoledronic acid (4mg) administered as a slow
infusion effectively brings down hypercalcemia. Bisphosphonates are preferentially
C. G. Nair (*)
Professor of Surgery, Endocrine Surgery Division, Amrita Institute of Medical Sciences and
Research Centre, Kochi, Kerala, India
R. Ramachandran
Department of Surgery, AIMS, Kochi, Kerala, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2024
C. G. Nair, S. J. Abraham (eds.), Surgical Management of Thyroid and
Parathyroid Diseases, https://doi.org/10.1007/978-981-97-3774-1_21
291
292
C. G. Nair and R. Ramachandran
incorporated into sites of active bone remodeling in conditions characterized by
accelerated skeletal turnover. Bisphosphonates inhibit bone resorption by internalization of osteoclasts. But the action is not limited to osteoclasts alone but also bone
remodeling also. The effects last for 3–6 months. About one-third of patients may
have acute phase reactions of fever, myalgia, and joint pain lasting for a few days.
Calcimimetic drugs like Cinacalcet (30mg twice daily) are used in secondary
HPT of renal origin. Cinacalcet was introduced for clinical use in 2004 and is occasionally used in PHPT but is not an effective substitute for parathyroidectomy. The
drug is widely used in patients with parathyroid dysfunction of renal origin.
The cardiovascular system is not a direct target organ in PHPT.But associated cardiac abnormalities such as diastolic myocardial dysfunction, left ventricular hypertrophy, hypertension, autonomic imbalance, metabolic disturbances, and endothelial
vasodilatory dysfunction are not uncommon [1, 2]. Mild forms of PHPT as seen in
asymptomatic disorder without cardiac risk factors may have normal cardiac morphology and function. But patients with more severe disease, as manifested by higher serum
calcium levels, may have an increased risk of morbidity and mortality from cardiac
diseases. The incidence of hypertension is also high among PHPT patients. So, it is
always advisable to do a complete cardiac assessment prior to parathyroidectomy.
Renal dysfunction is not rare as part of metabolic dysfunction in severe diseases
and usually gets corrected by measures taken to correct hypercalcemia. Obstructive
uropathy with or without renal dysfunction merits early urological intervention
before parathyroidectomy.
Vocal cord assessment is mandatory prior to exploration.
Patients who have severe bone demineralization are likely to develop hungry
bone syndrome during the postoperative period. Many such patients have vitamin D
deciency of insufciency but active correction may exacerbate the hypercalcemia
transiently. Patients who have shreds of evidence of bone loss are given 1–25 OH
vitamin D preparation on the day before operation and continued after the operation
before evident hypocalcemia manifests.
21.1.1 Preoperative Counselling
Just like any other interventional procedure patients should be informed about the
details of the disease, need for operation, and likely consequences of the procedure.
Awareness of parathyroid glands and diseases related to them is sparse among the
general public. The vivid functions of the parathyroid hormone may have to be
explained since many fail to understand the logic of operating on the neck for renal
stones or fragility fractures.
For focused procedure is done through a small strategically placed incision and
the resultant scar could be inconspicuous. But unlike this popular concept occasionally the scar hypertrophy is troublesome. Concern about an ugly scar on the exposed
area of the neck is high and hence surgeon should take an effort to reduce this
anxiety.
21 Parathyroidectomy: Surgical Techniques
293
The concern of hungry bone syndrome in patients with considerable bone mineral
loss is high. The prolonged need for calcium and dihydroxy vitamin D supplementation is to be explained. The surgeon should ensure adequate compliance regarding
the timely intake of tablets. The probable chances of distressing symptoms of hypocalcemia are explained adequately. Those rare patients with a lack of compliance
may require unexpected hospital visits for intravenous calcium administration. These
patients require a monthly visit to laboratory estimation serum calcium, serum PO4
and alkaline phosphatase for dose adjustment of supplementation.
Vitamin D deciency is usual in PHPT patients and adequate supplementation is
necessary for the postoperative phase.
Recurrent laryngeal nerve injury is a rare complication of parathyroidectomy.
Preoperative assessment of the larynx to assess the movement and function of the
vocal cord is always indicated. In case of such catastrophic event of palsy or paresis
of video-laryngoscopy is done to assess the extent of the damage. The details of
management protocol are given elsewhere and have to be briefed to the patient
before surgery.
21.1.2 Desirable Additional Supports
A portable ultrasound machine in the operation theatre is of great help during exploration when preoperative imaging was inconclusive.
An intraoperative gamma probe is available only in selected institutions but supports surgeons efciently in patients who are undergoing re-explorations. Gamma
probe also helps to identify rare parathyroid adenomas which retain tracer for short
time only (“rapidly washing out adenomas”).
Laboratory service available close to operation theatre with facilities to do rapid
PTH assays is desirable. Intraoperative PTH assay is essential when focused parathyroidectomy is planned.
The pathology laboratory equipped to do frozen section studies helps to differentiate structures such as thyroid remnants, cysts of the thymus, and
lymph nodes.
1. Anesthesia—The procedure may be done under local anesthesia given as cervi-
cal plexus block and inltration at the line of incision. But many of the parathyroid lesions of patients in symptomatic diseases of Asiatic countries are bigger
in size compared to those of asymptomatic PHPT patients. Hence, these lesions
used to have a complex relation to vital structures and are highly vascular. So
general anesthesia with adequate muscle relaxation is preferred if the general
condition is satisfactory (Fig.21.1).
2. When facility for intraoperative PTH assay is available 4ml blood is drawn
before induction and administration of anesthetic agents. The transporting team
is instructed to transfer quickly to the laboratory protected in icepack to minimize disintegration of the hormone (Fig.21.2).
294
Fig. 21.1 The patient
positioned after completing
administration of general
anesthesia
Fig. 21.2 Blood draw for
IOPTH assay
C. G. Nair and R. Ramachandran
Fig. 21.3 The incision
marked
3. Position: The patient is positioned supine with a support behind the shoulder
blades. The head is steadied on a ring. It is very important to avoid excessive
extension strain on the cervical spine (Figs.21.3, 21.4 and 21.5).
4. If an ultrasound machine is available reassessment of anatomical localization is
done and the location is marked with a permanent marker pen. This procedure
may be done in the ultrasound room if the facility is not available in the operation theatre.
5. Neck is painted and the patient is draped (Fig.21.6).
21 Parathyroidectomy: Surgical Techniques
Fig. 21.4 Patient
positioned
Fig. 21.5 Surgeon
performed localization
295
Fig. 21.6 Patient painted
and draped
6. Operating surgeon stands on the side of the lesion and the rst assistant on the
other side. The scrub sister is on the left side of the table with the instrument
spread over Mayo’s trolley.
7. Energy sources for hemostasis are connected to the patient. Suction equipment
is kept ready and connected with the ne-tip with control. The intensity of
energy sources is set to the minimum after the initial steps.
296
C. G. Nair and R. Ramachandran
8. Incision is planned based on the location of the lesion and the chosen type of pro-
cedure. For lesions from inferior parathyroid 2–3cm transverse incision at the
marked area is sufcient. If the ultrasound imaging indicates a large lesion close to
the trachea-esophageal groove larger incision is planned. If total neck exploration
is planned the incision shall be as for thyroidectomy. A ve- to six- centimeters- long
transverse incision given on the lower part of the front of the neck reaching equally
on both sides from the midline, gives good exposure (Figs.21.7 and 21.8).
Fig. 21.7 The incision
Fig. 21.8 The
subcutaneous tissue and
investing layer divided
21 Parathyroidectomy: Surgical Techniques
297
9. Incision is deepened to expose the investing layer of deep fascia. For focused
parathyroidectomy, further exposure is done by the division of strap muscles.
The investing layer of the deep fascia is divided transversely and strap muscles
are exposed. The median raphe is divided and a blunt hemostat is introduced
lifting the strap muscles from the anterior surface of the thyroid. The anterior
jugular vein is a potential source of bleeding and should be controlled effectively. The strap muscles are divided with bipolar diathermy for controlling
bleeding from cut edges (Figs.21.9, 21.10, and 21.11).
When total neck exploration is planned upper and lower skin aps are made to
expose the investing layer of fascia. The thyroid gland is exposed by the traditional method of dividing investing layer of fascia vertically in the midline.
10. But inferior parathyroid glands are generally located in the vicinity of the lower
pole of thyroid lobes. Adequate mobilization of the thyroid lobe with minimal
damage to its blood supply is necessary to locate the lesion. The parathyroid
gland is mostly seen anterior to RLN on the side of the trachea or rarely embedded in vestigial remnants of the cervical thymus.
Division of strap muscles exposes the surface of the thyroid gland and dissection is extended laterally between the Sternocleidomastoid muscle and lateral
aspect of the thyroid. Middle thyroid vein and rarely Kocher’s vein are encoun-
Fig. 21.9 Division of the
strap muscles
Fig. 21.10 The division
of strap muscle continues
exposing the thyroid
298
Fig. 21.11 The thyroid
lobe exposed
Fig. 21.12 Exposure of
lobe of thyroid
C. G. Nair and R. Ramachandran
tered during the dissection and are secured effectively. The thyroid lobe is
mobilized medially exposing the trachea-oesophageal grove. A lightweight
Babcock tissue holding forceps is applied and the lobe is held medially by the
assistant on the other side. Minimal traction is given to avoid injury of the thyroid gland since subsequent bleeding adds to the difculty in dissection and
identication of parathyroid lesions and vital structures. A Langenbeck retractor is introduced to expose the lateral aspect of the lobe. This retractor is held
by the second assistant on the side of the operating surgeon (Fig.21.12).
11. The inferior or 3rd parathyroid lesions may be easily visible now close to the
lower pole of the thyroid gland. The inferior parathyroid lesion is occasionally
placed close to the lower pole and discretely visible in the early phase of dissection. These lesions are usually anterior to recurrent laryngeal nerve and mostly
derive their blood supply from the inferior thyroid artery. Usually, adenomas
are chocolate brown in color and are very soft inconsistency. The thyroid lobe
is held medially and the Langenbeck retractor holds the SCM muscle laterally
exposing the trachea-esophageal grove. Loose areolar tissue is gently separated
exposing the recurrent laryngeal nerve (RLN) (Figs.21.13, 21.14, and 21.15).