Perioperative management - Excision of solitary parathyroid adenoma

  1. 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
  2. Contraindications

    • None
  3. 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.
  4. 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)
  5. 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

General anesthesiaAdministration of short-acting muscle relaxants only during anesthesia induction

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