Perioperative management - Excision of solitary parathyroid adenoma

All cases of primary hyperthyroidism:

• Because of the wide-ranging morbidity in hyperkalemia, parathyroidectomy (PTX) is indicated not only in all symptomatic, but usually also in asymptomatic cases.
• Parathyroid adenoma → surgical procedure: Adenoma excision

• None

• Hyperparathyroidism in normal renal function with subsequent hypercalcemia
• Additional lab studies (phosphate, alkaline phosphatase, albumin/total protein; optionally T3, T4, TSH)
• Ruling out neoplasia (thyroid neoplasia, multiple endocrine neoplasia)
• Laryngoscopy (vocal cord function)

Location work-up

• Ultrasonography, MIBI-SPECT, (CT, MRI, PTH selective venous sampling)
• →consistent location carries a high degree of probability for single adenoma
• →however, if both modalities demonstrate negative or conflicting locations for parathyroid adenoma, this increases the probability of multiple adenomas.

• Intraoperative peripheral venous PTH study (IOPTH) for ruling out/confirming multiple adenomas→PTH level as “pre-incision” baseline.
• Pre- and postoperative laryngoscopy
• Neuromonitoring with vagus stimulation pre- and post-resection
• Standardized intraoperative neuromonitoring (ION)
• Verifiable documentation of the stimulated EMG of the ipsilateral vagus nerve before and after resection (for medicolegal reasons)

• Usual risk in surgical procedures (bleeding, infection, secondary wound healing, revision surgery)
• Undetectable adenoma(s) and revision surgery
• Persistent hyperparathyroidism
• Postoperative hyperparathyroidism
• Vocal cord paralysis
• Parathyroid autotransplantation into muscles of the neck or forearm
• Exploration of the thyroid, with possible excision in case of abnormalities
• Pneumothorax
• Possibly postoperative calcium supplementation
• Recurrence