Excision of solitary parathyroid adenoma - general and visceral surgery

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date of publication: 25.04.2008

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  • Skin incision

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    29-6

    Incise the skin 2 finger widths (2-3 cm) superior to the suprasternal notch between the bellies of the left and right sternocleidomastoid muscles (so-called Kocher or collar incision). Divide the platysma with electrocautery.

    Note: In single parathyroid adenomas with well-known location the skin incision may be much smaller than, e.g., in thyroidectomy.

  • Subcutaneous dissection, midline division

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    29-7

    Divide the subcutaneous tissue and enter the white line of the neck. Between forceps divide and ligate any superficial jugular veins in the cervical fascia.

    Tip: Simple ligatures of the cervical veins often slip off during surgery. Closure is best accomplished by suture-ligation (PDS 3/0).

  • Exposing the thyroid

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    Retract the strap muscles of the neck from the anterior aspect of the thyroid. Expose both thyroid lobes circumferentially, expose the trachea and divide any superficial vessels encountered.

  • Locating the parathyroid adenoma

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    At first, no tumor can be palpated on the right side. For better view, first expose the superior pole of the right thyroid lobe and divide the vessels of the superior pole close to the lobe. Now carefully bring out the right lobe.

    Expose the normal-sized superior right parathyroid which is found at its typical location. While exposing the inferior right parathyroid with its diameter of at least 1 cm, it clearly appears as an adenoma. Now expose the recurrent laryngeal nerve and carefully free the parathyroid adenoma. Close the vessels with clips or bipolar electrocautery.

    Note:

    The following information is important for locating the parathyroid glands: The superior parathyroids are located superior to the inferior thyroid artery and posterior to the recurrent laryngeal nerve. The inferior parathyroids are located inferior to the inferior thyroid artery and anterior to the recurrent laryngeal nerve. The fawn color of the parathyroids makes them stand out from the adjacent tissue.

    In most cases, the parathyroids will be found close to where the recurrent laryngeal nerve crosses the inferior thyroid artery.

  • Excising the parathyroid adenoma

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    Clamp the parathyroid adenoma and pull it toward you. Rule out injury to the recurrent laryngeal nerve by intraoperative neuromonitoring (ION). Now clip the vascular pedicle and excise the parathyroid Adenoma in toto and without injury to its capsule.

    Tip: “Biochemical fast frozen section” by intraoperative PTH measurement proves the removal of hyperactive parathyroid tissue and rules out multiple adenomas.

  • Wound closure

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    Carefully manage any bleeding; if needed, place a hemostatic in the wound. Now close the strap muscles of the neck with interrupted sutures. Close the skin with a running subcuticular suture. Apply dressing with Steri-Strips and adhesive tape.