Parathyroidectomy for Secondary or Tertiary Hyperparathyroidism

Abstract

This chapter describes parathyroidectomy for secondary or tertiary hyperparathyroidism. It lists the indications, essential steps, common technical variations, and complications of the procedure. A detailed template operative dictation note is included.

Indication

• Secondary hyperparathyroidism

• Tertiary hyperparathyroidism

Essential Steps

• 1. Develop subplatysmal flaps and divide the strap muscles in the midline.

• 2. Identify, biopsy, and excise all parathyroid glands, or leave viable remnant of one gland.

• 3. Verify that pathology of each excised gland is parathyroid tissue.

• 4. Reimplant small pieces of half a parathyroid gland into the brachioradialis muscle of the nondominant forearm (for total parathyroidectomy).

• 5. Obtain meticulous hemostasis and close incision(s) without drains.

Note These Variations

• Three-and-a-half gland excision with half gland left on vascular pedicle

• Cryopreservation of parathyroid tissue

Complications

• Hypocalcemia

• Recurrent laryngeal nerve injury

• Post-op bleeding resulting in tracheal compression and airway obstruction

Template of Operative Dictation

Preoperative Diagnosis

Secondary/tertiary hyperparathyroidism

Procedure

Total parathyroidectomy with autotransplantion into right/left forearm (or three-and-a-half gland parathyroidectomy)

Postoperative Diagnosis

Same

Indications

This ___-year-old male/female developed secondary/tertiary hyperparathyroidism unresponsive to medical therapy. Total/three-and-a-half gland parathyroidectomy is indicated.

Description of Procedure

Time-outs were performed using both preinduction and pre-incision safety checklists to verify correct patient, procedure, site, and additional critical information prior to beginning the procedure. Following smooth induction of general anesthesia, both arms were tucked at the sides and all bony prominences were padded. A soft roll was placed under the shoulders and the patient was positioned in a modified beach chair position with the neck extended. The neck and upper chest were prepped and draped in a sterile fashion. A baseline PTH was drawn from the peripheral IV/arterial line. If three-and-a-half gland parathyroidectomy is performed: prior to the operation, the right/left superior/inferior gland was chosen for preservation, based on scintigraphic imaging.

A ___-cm incision was made in a skin crease positioned approximately two fingerbreadths superior to the sternal notch. The subcutaneous tissues and platysma were divided with electrocautery. Subplatysmal flaps were developed. The strap muscles were divided in the midline and retracted laterally.

The right thyroid lobe was rotated medially. The loose areolar attachments were dissected bluntly and using electrocautery. The right superior/inferior parathyroid gland was identified (describe location of the gland). A biopsy of the gland was sent to pathology. The gland was gently dissected from the surrounding tissues down to its pedicle, which was clamped and tied with a 3-0 silk suture. The parathyroid gland was excised and placed in a labeled cup on ice. The right superior/inferior parathyroid gland was identified (describe location of the gland). It was biopsied and dissected from the surrounding tissues down to its pedicle, which was clamped and tied with a 3-0 silk suture. The parathyroid gland was excised and placed in a separate labeled cup on ice.

Next the left thyroid lobe was rotated medially and a similar procedure carried out to identify the left parathyroid glands. Each was excised, biopsied, and placed in separate labeled cups on ice. The left superior parathyroid gland was identified (describe location of the gland). The left inferior parathyroid gland was identified (describe location of the gland). Pathology from each gland returned consistent with parathyroid tissue. The cervical thymus was dissected free on both sides and removed, ligating its inferior veins with 3-0 silk suture. A post-excision PTH level was sent approximately 15 min after removal of the glands.

If three-and-a-half gland parathyroidectomy is performed: the right/left superior/inferior gland was selected for preservation. A biopsy of the gland was sent to pathology. The gland was dissected free from surrounding tissues, keeping the artery and vein intact. The gland was divided sharply by placing a clip across it and then incising the parenchyma. The excised portion of the gland was placed in labeled cup of ice.

The neck wound was copiously irrigated and hemostasis was achieved. The strap muscles and platysma were reapproximated with interrupted 3-0 Vicryl sutures. Approximately 10 cc of 0.25 % Marcaine was injected subcutaneously. The skin was reapproximated with a running 4-0 Monocryl subcuticular suture. Surgical glue was placed over the incision.

The right/left forearm was extended on an arm board and then prepped and draped in a sterile fashion. An incision was made in the right/left lateral forearm. Using blunt dissection, ____ pockets were carefully made in the belly of the brachioradialis muscle. Approximately half of the right/left superior/inferior parathyroid gland was divided into multiple 1–3 mm sections using a scalpel. Several pieces of parathyroid tissue were placed in each pocket. Each pocket was marked with a clip and closed with a 4-0 Prolene suture. The deep dermis was reapproximated with interrupted 3-0 Vicryl sutures. The skin was reapproximated with a running 4-0 Monocryl subcuticular suture.

A debriefing checklist was completed to share information critical to postoperative care of the patient. The patient tolerated the procedure well and was extubated and taken to the postanesthesia care unit in stable condition.