Background Information:

What are the other Names for the Procedure?

• Parathyroid Surgery
• Removal of Parathyroid Gland
• Total Parathyroidectomy

What is the Parathyroidectomy surgical procedure?

Parathyroidectomy is a surgical procedure that involves the removal of one or more abnormal or enlarged parathyroid glands. The procedure is also known as Removal of Parathyroid Gland.

What part of the Body does the Procedure involve?

• The Parathyroidectomy operation involves the front of the neck
• There are usually 4 parathyroid glands, two on each side of the thyroid gland. These are called superior (upper) and inferior (lower) parathyroid glands
• Often, enlarged parathyroid glands may occur in the chest. In this scenario, the operation may have to be carried out in the chest too

Why is the Parathyroidectomy surgical procedure Performed?

• The parathyroid glands produce a hormone called ‘parathyroid hormone’ (PTH). PTH plays an important role in maintaining blood calcium levels
• Enlarged parathyroid glands (usually due to tumor) result in excessive levels of PTH, which in turn raises blood calcium levels. This may be harmful to a number of organs in the body; chiefly the bones and kidneys
• Occasionally, in patients with advanced kidney failure, the patient may have low or normal calcium levels. But the parathyroid glands may be secondarily stimulated, resulting in a high PTH level, which in itself has harmful effects
• Often, an operation is therefore required, to treat the high levels of PTH being produced by the abnormally enlarged parathyroid glands
• The enlargement is almost always due to a benign disease condition. Very rarely, parathyroid tumors may be cancerous

What are some Alternative Choices for the Procedure?

• A Parathyroidectomy procedure is usually the most effective treatment for over-activity of the parathyroid glands
• However, not all patients with the condition need operation. Some of them may simply be actively monitored
• There are also medications that may help to reduce the high calcium levels associated with the condition, and other medications that counteract the negative effects of high PTH levels on the bones
• These alternatives have a number of limitations and need to be discussed with the associated physician or surgeon

What are the Recent Advances in the Procedure?

• The operation may be performed via a small incision on the neck. This is called a keyhole operation (minimally-invasive Parathyroidectomy)
• In some centres, the operation is performed via an incision in the armpit or chest. This is done as some patients are very keen to avoid a neck scar
• A robot may also be used to perform the operation in some hospitals, although there is no evidence that robotic surgery is better than a conventional surgical operation

Note: Please discuss with your physician the risks and benefits of robotic surgery over conventional surgical methods.

What is the Cost of performing the Parathyroidectomy surgical procedure?

The cost of Parathyroidectomy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding Parathyroidectomy surgery on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

Prior to Parathyroidectomy surgical procedure:

How is the Parathyroidectomy surgical procedure Performed?

There are two main approaches to a Parathyroidectomy operation, performed on the parathyroid glands:

• In one approach, the surgeon aims to identify all 4 parathyroid glands with the intention of removing all abnormal glands; but ensuring that at least a small amount of tissue is retained, so as to avoid the problems with very low PTH
• In the other approach (which is currently in vogue), scans are performed before the operation to identify the abnormal gland before surgery. If the scans are clear, then the operation may be focused (targeted) on identifying only the abnormal gland and removing it. The second approach is often called targeted or minimally-invasive Parathyroidectomy (MIP)
• The Parathyroidectomy procedure is usually performed via a horizontal incision over the lower part of the front of the neck (often called a ‘collar’ incision). The muscles over the thyroid gland in the front of the neck are separated (or divided) to get access to the thyroid and parathyroid glands
• The abnormal parathyroid gland(s) is then separated from several vital structures around it taking care to divide the blood vessels running to the gland, and avoiding injury to these structures
• Occasionally, the operation may be performed via a small (key-hole) incision over the neck, or an incision away from the exposed part of the neck (such as the underarm). This may be an important consideration for some people keen to avoid a visible scar as much as possible

Where is the Procedure Performed?

• A Parathyroidectomy is performed at a hospital, usually under a general anesthetic
• In some instances (especially where it is clear that only one abnormal gland needs to be removed), it may be possible to perform this procedure under a local anesthetic

Who Performs the Procedure?

A general surgeon or head and neck surgeon with interest in thyroid disease performs the Parathyroidectomy procedure.

How long will the Procedure take?

• The time for a Parathyroidectomy procedure is very variable and ranges from 45 minutes to 3 hours depending on the type and extent of surgery, the location of parathyroid glands and the need for additional procedures.
• Occasionally, the location of parathyroid glands may not be obvious as these glands are located in ectopic (other than usual) areas away from the thyroid gland
• Sometimes, parathyroid glands may be hidden within adjacent organs, such as the thyroid gland and thymus

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Peptic Ulcer Surgery procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• If the patient’s blood calcium level is very high, it may be necessary for this to be lowered with fluids and medications before the operation
• Local anesthesia may be used at the time of surgery to reduce pain following the procedure. Please do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while (for at least 4-6 weeks), before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 4 hours prior to the surgical procedure, but this duration depends on when and where the procedure is arranged. Please discuss with the treating team at your hospital
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Parathyroidectomy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Parathyroidectomy surgical procedure?

• The diagnosis (medical condition) for which parathyroid surgery is required is usually primary hyperparathyroidism. Blood and urine tests are required to confirm this diagnosis before surgery is considered
• Tests may also be needed to determine, if the disease has affected other organs, such as the bones and kidneys
• In addition (especially where a targeted or minimally-invasive operation is planned), scans are needed to confirm the position of the abnormally enlarged parathyroid gland before surgery
• Other blood and urine tests, chest x-ray and an electrocardiogram ((ECG) may occasionally be required to examine, if a patient can safely have a general anesthetic

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Parathyroidectomy procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who is involved in performing this procedure?
• Where is the procedure performed? 
• What are the complications that might take place, during and after the surgery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures do you perform on a regular basis?
• Are there any follow-up tests and/or periodic visits required after the procedure?
• What are the costs involved?

During the Parathyroidectomy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

• General anesthesia is usually employed during the Parathyroidectomy procedure
  
• Occasionally, this operation may be done under local anesthesia, particularly if a targeted or minimally invasive procedure (MIP) is being performed to remove one enlarged parathyroid gland

How much Blood will you lose, during the Procedure?

The amount of blood loss in a Parathyroidectomy procedure is usually minimal.

What are the possible Risks and Complications during the Parathyroidectomy surgical procedure?

The specific risks of Parathyroidectomy surgical procedure include the following:

• Laryngeal nerve injury: It can cause hoarseness, weakness and a breathy voice, with or without swallowing difficulties. Occasionally, there is a complete loss of voice. The injury is often temporary and most patients report a full recovery
• Infection and bleeding: These are uncommon risks of a parathyroid operation. Occasionally, a re-operation may be needed in patients who have either significant bleeding or a serious infection after surgery.

What Post-Operative Care is needed at the Healthcare Facility after the Parathyroidectomy surgical procedure?

• As part of routine postoperative care immediately after surgery, patients are sent to an area of the hospital called the postoperative recovery room (or PACU)
• Here, the patient’s blood pressure, heart rate and respiration, are closely monitored and any pain following the operation is treated
• After a short period of time in PACU, patients may be sent to the ward for recovery

Other related care depends on the extent of Parathyroidectomy surgical procedure. In many centers, a routine postoperative check of the larynx (voice box) may be performed.

• Blood calcium levels and PTH levels are also checked routinely
• Although, day surgery is performed in many centers, patients are routinely asked to stay overnight at the healthcare center
• A follow-up visit to the hospital is required to check the voice, site of surgery, and calcium levels. The timing and extent of these checks depend on the results of initial tests and vary between centers

After the Parathyroidectomy surgical procedure:

What are the possible Risks and Complications after the Parathyroidectomy surgical procedure?

The specific risks of a Parathyroid Surgery include the following:

• Failure of the operation to normalize high calcium levels in patients with primary hyperparathyroidism. This should usually be lower than 5%
• Low calcium levels: This could be due to the increased uptake of calcium by the bones following the correction of high PTH levels. Occasionally, the low calcium may be due to inadequate residual parathyroid tissue. This can be treated with calcium and vitamin D supplements
• Hypertrophic scar and keloid formation: As with any surgical operation, hypertrophic scars (that are prominent and thick) or keloid scars (prominent scars that tend to itch and can worsen with time) may develop at the site of surgery, which may require treatment

What is the Prognosis after the Surgery?

A full recovery is usually expected in patients after the Parathyroid Surgery, without any serious complications being noted.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Pain that worsens and swelling around the surgical wound
• Bleeding or fluid drainage from the surgical wound
• Symptoms of low calcium levels that include numbness, tingling or ‘pins and needles’ in the tips of fingers, toes, or around the mouth, nausea and ‘feeling unwell’
• Difficulty in swallowing
• Feeling unwell for any reason during the first few weeks after surgery

What Post-Operative Care is needed at Home after the Parathyroidectomy surgical procedure?

At home, the following post-operative care is recommended, after a Parathyroidectomy procedure:

• Slowly resume regular/daily activities as early as possible, which aids in faster recovery
• Resume showering 48 hours after surgery, but keep the wound clean and dry before and after showering. The surgical wound may be gently washed with a mild, unscented soap
• If there was a wound dressing in place at the time of discharge, replace dressing after showering
• Complete the course of prescribed medication as advised by your physician
• Take thyroidal hormone medications regularly, if prescribed
• Avoid all activities that are physically strenuous for about 6 weeks after surgery
• Resume driving 2 months after being discharged from the hospital, or only when advised by your physician
• Avoid sex till a complete healing has taken place (or follow your physician’s advice)

How long does it normally take to fully recover, from the Procedure?

This time for recovery is variable and depends on the extent of surgery and indication for the procedure (reason for performing the procedure). Most individuals are able to fully recover in about 4-6 weeks’ time.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later archived or disposed, as per the standard protocols in the treating hospital.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Parathyroidectomy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• A hospital
• An anesthesiologist (if anesthesia was administered)
• A pathologist
• A general surgeon

The patient is advised to inquire and confirm the type of billing, before the Parathyroidectomy surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA