Perioperative management - Excision of solitary parathyroid adenoma - general and visceral surgery
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Indications
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
Contraindications
- None
Preoperative diagnostic work-up
- 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.
Special preparation
- 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)
Informed consent
- 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
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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