Excision of solitary parathyroid adenoma

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anterior triangle of the neck

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    Situated between the anterior margin of the sternocleidomastoid muscle, the mandibula and the jugular fossa, the anterior cervical triangle near the hyoid bone comprises the suprahyoid and subhyoid muscles, vessels, nerves and the thyroid. The only important subhyoid muscles in thyroid surgery are the medial

    • sternohyoid muscle (sternum → hyoid bone) which covers the
    • sternothyroid muscle (sternum → thyroid cartilage of the larynx) and more laterally the
    • omohyoid muscle (scapula → intermediate tendon→ hyoid bone)

    because they partly cover the thyroid gland and must be retracted laterally.

    Blood vessels

    Before dividing into the internal and external carotid artery, its two main branches, at the superior margin of the thyroid cartilage at the level of its carotid sinus (pressoreceptors for the blood pressure and chemoreceptors for the blood gases), the carotid artery courses in the carotid sheath immediately lateral to the trachea and esophagus. Here, it touches the left and right thyroid lobe as a major blood vessel. The internal jugular vein arises from the sigmoid sinus in the skull, collects the blood from the head and neck, and while coursing caudad it first accompanies the internal carotid artery in the carotid sheath before pursuing a more lateral course, enclosing the lateral aspects of the common carotid artery and vagus nerve (CN X).

    Nerves

    The ansa cervicalis (superior and inferior roots, from C1-C3), which innervates these three above muscles of the anterior triangle of the neck, and the transverse nerve of the neck (from C2/3, innervation of skin and platysma) courses cephalocaudad lateral to the thyroid and next to the vagus nerve and its superior branch to the larynx (superior laryngeal nerve → anterior cricothyroid muscle and mucosa of the superior laryngeal half).

    Fascial layers

    The skin of the anterior triangle of the neck covers several fascial layers (all belonging to the cervical fascia) with distinctive features:

    • The superficial lamina invests all structures of the neck, except for the platysma, and separately invests the sternocleidomastoid muscle as well as the posterior aspect of the trapezius muscle (accessory nerve XI),
    • with the medial pretracheal lamina investing the infrahyoid muscles and
    • the deep prevertebral lamina coursing outside the surgical field between the esophagus and spine.

    Just like the lateral vascular and nerve pedicle (carotid artery, internal jugular vein and vagus nerve), the trachea and thyroid / parathyroids also have their own organ fascias. With their three-dimensional configuration, the fascias invest compartments interspersed with spaces which extend into the mediastinum and thus represent potential routes of infection.

  • Thyroid region

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    The unpaired thyroid (glandula thyroidea) and the 4 parathyroids (glandula parathyroidea) are part of the endocrine organ system. The thyroid gland is located in the anterior neck lateral and inferior to the thyroid cartilage, is made up of a left and right lobe and the isthmus which bridges both lobes. The lobes cover the lateral superior rings of the trachea as well as the anterior aspect of both the cricoid and thyroid cartilage; the isthmus is located in the midline at the level of the second and third tracheal ring. The organ is invested by its own capsule of connective tissue (capsula fibrosa) and covered anterolaterally by the infrahyoid muscles (sternohyoid, sternothyroid and omohyoid) and the pretracheal lamina. Due to its embryology and descent (via the thyroglossal duct) from the base of the tongue (foramen caecum) to its later location, its path may leave cysts or ducts to the foramen caecum, as well functional glandular tissue (e.g., pyramidal lobe).

    Blood supply

    Arteries from the external carotid (→ superior thyroid artery) and the subclavian artery via the thyrocervical trunk (→ inferior thyroid artery) with their small anterior and lateral/posterior branches supply the thyroid gland with blood. The thyroidea ima artery, an inconsistent but noteworthy artery arising directly from the aortic arch or the brachiocephalic trunk terminates in the thyroid from below. Venous drainage from this endocrine organ is via corresponding veins (superior and medial thyroid vein → internal jugular vein, inferior thyroid vein → brachiocephalic vein) and has systemic significance.

    Lymphatics and nerves

    Lymphatic drainage from the thyroid is paratracheal and to the deep cervical lymph nodes. Particular attention must be paid to the recurrent laryngeal nerve (from the vagus nerve (CN X), on right: looping around the subclavian artery; on left: looping around the aortic arch). It travels cephalad in the groove between trachea and esophagus to the larynx, where it supplies the sensory mucosal innervation of the inferior half of the larynx and all laryngeal muscles except the anterior cricothyroid (“anticus”).

    The four parathyroids (glandula parathyroidea), small oval glands on the posterior aspect of the thyroid lobes, are supplied by the inferior thyroid arteries.

  • Topography

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    Due to their proximity, thyroid surgery runs the risk of injuring not only structures such as the recurrent laryngeal nerve and the parathyroids on the posterior aspect of the organ, but also parts of the sympathetic trunk or vessels and nerves adjacent to the common carotid artery.

  • Anatomy and function of the parathyroids

    While the barely lentil-sized, paired parathyroids are usually found on the posterior aspect between the fibrous and external capsule of each lobe, sometimes they are located within the thyroid tissue itself.

    Most often, the superior parathyroids are at the level of the inferior margin of the cricoid cartilage, superior to the crossing of the inferior thyroid artery with the recurrent nerve, but posterior to the latter.

    The most common location of the inferior parathyroids is at the level of the third and fourth tracheal ring or inferior to the crossing of the inferior thyroid artery with the recurrent nerve, but anterior to the latter.

    The number and location of the parathyroids vary greatly, and in 95% of cases there are at least 4 parathyroid glands. Due to the long embryological migration of these glands, quite often their locations may vary and are atypical. They have been found in the connective tissue of the neck superior or inferior to the thyroid gland. Cephalad migration up to the angle of the jaw (carotid bifurcation) and particularly caudad into the thyrocervical ligament or even migration with the thymus into the anterior mediastinum has been described. Locations within the thyroid are mostly in the inferior third of the thyroid lobes.

    More than 80% of the parathyroid tissue is supplied by the inferior thyroid artery. The blood supply for the remainder comes from the superior thyroid artery and branches arising from the anastomoses between both thyroid arteries.

    The main function of the parathyroids is the formation and secretion of parathyroid hormone (PTH), a polypeptide comprising 76 amino acids.

    PTH controls the calcium metabolism by up-regulating renal re-absorption in the distal tubule. PTH release is primarily controlled by the serum calcium level. Renal hydroxylation of 25-cholecalciferol into1,25-dihydroxycholecalciferol, the active metabolite of vitamin D3, is controlled by PTH and regulates the intestinal absorption of calcium and phosphate.

    Most of the serum calcium binds to albumin (80%), but only the free, i.e., ionized, calcium exhibits physiological significance. The calcium-albumin binding depends on the pH and is strengthened by alkalosis.

    Since it controls the calcium metabolism, PTH impacts directly on the serum level of phosphate and magnesium.

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 26.04.2008
  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Skin incision

    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

    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.

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Intraoperative complications

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  • Postoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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