The difficulties of parathyroidectomy include wide variations in parathyroid gland location among patients, inadequacies of localization studies, and the possibility of having more than four parathyroid glands. Experienced endocrine surgeons can accurately recognize differences in size and shape among the parathyroid glands and reliably estimate their weights. Several studies have shown that parathyroid surgery, when performed by high-volume surgeons and in high-volume centers, has higher cure rates, fewer complications, lower cost, and a shorter length of stay.
Bilateral Parathyroid Exploration (Bilateral Parathyroid Examination, Open Parathyroid Gland Removal)
It is a standard method aimed at exploring all parathyroid glands by reaching the possible locations of all parathyroid glands. These are operations performed in cases where multigland disease is identified or investigated and have high cure rates. In situations where rapid parathormone assessment that can be performed during the operation (intraoperative parathyroid hormone (IOPTH) monitoring) is not possible or is at the surgeon’s discretion, bilateral parathyroid exploration is the preferred operative strategy. It may also be performed in the following situations:
- When the adenoma cannot be localized in preoperative imaging studies or when bilateral foci are detected
- If patients have familial primary hyperparathyroidism (PHPT). Such patients are estimated to have involvement of more than one gland. Since some may have undiagnosed multiple endocrine neoplasia (MEN) syndrome type 1, bilateral parathyroid exploration should also be considered for young men with apparent sporadic PHPT.
- When concomitant thyroid disease requires surgical resection.
- Because localization studies require radiation, they cannot be performed in pregnant patients. These patients require bilateral examination. However, if ultrasonography shows a single adenoma , a focused approach may be followed.
- If the patient has lithium-induced hyperparathyroidism. Lithium-associated PHPT has a high likelihood of multigland involvement.
Focused Parathyroidectomy (Minimally Invasive Parathyroid Gland Removal)
Focused parathyroidectomy is ideally used in patients with a single parathyroid adenoma confirmed clinically and by imaging. It is not recommended for patients with known or suspected multigland disease. This approach is suitable for patients who have clear imaging suggesting unilateral pathology, who do not have an accompanying thyroid disease recommendation requiring surgical intervention, and who do not have a family history of MEN syndrome. When the adenoma is not detected in preoperative localization studies or when the adenoma cannot be found during focused parathyroid exploration, bilateral parathyroid exploration should be performed. Therefore, focused parathyroidectomy should be performed by surgeons who are also experienced in bilateral neck exploration.
The effectiveness of the method can be increased with rapid parathormone testing during the operation. Since a smaller incision is made in the focused approach, it may lead to less pain, a smaller scar, and a lower rate of decrease in blood calcium.
Endoscopic & Robotic Parathyroidectomy (Closed Parathyroid Gland Removal)
Special endoscopic and robotic surgery systems have recently begun to be used for parathyroid surgery. Endoscopic parathyroidectomy candidates are patients with nonfamilial PHPT whose disease site is precisely identified preoperatively. Unsuitable patients are those with prior neck surgery, familial PHPT, large goiters, multigland disease, obesity, and suspicion of parathyroid carcinoma.
In endoscopic and robotic parathyroidectomy, central approaches through the neck and remote-access approaches through the armpit have been described, but surgical scarring is present in both. In the scarless parathyroid surgery described in recent years through the inside of the lip, the parathyroid gland is reached and removed via incisions made inside the lip. There is no scar in this surgery.
