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

General anesthesia

Administration of short-acting muscle relaxants only during anesthesia induction but not during ION.

• Supine, with head reclined (as in thyroidectomy)
• Both arms adducted

Unilateral findings: Surgeon on contralateral side to be operated on; bilateral findings: After completion of one side, change to other side. First assistant facing the surgeon, second assistant cranial to first assistant, and scrub nurse ipsilateral with surgeon at hip-level of patient.

• Thyroidectomy set
• Neuromonitoring equipment plus vessel loops for the vagus nerve
• Titanium clips
• recommended: Surgical telescopes for surgeon

Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).

This link will take you to the International Guideline Library.

Postoperative care: Remove Redon drain on postoperative day 1; serum calcium follow-ups, manage any hypocalcemia, laryngoscopy before discharge.

Deep venous thrombosis prophylaxis: Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.

Note: Renal function, HIT II (history, platelet check)

This link will take you to the International Guideline Library.

Ambulation: Immediate mobilization

Physiotherapy: Not required

Diet: Unrestricted

Bowel movement: Laxatives may have to be started on postoperative day 2

Work disability: 1-2 weeks