Parathyroid Surgery

For primary hyperparathyroidism, the only cure is an operation.

Fortunately, when performed by an experienced surgeon, the operation is a quick outpatient procedure - meaning that you can go home the same day, no need to stay overnight at the hospital.

During the operation, one or more diseased parathyroid glands are removed. Primary hyperparathyroidism is most often caused by a benign tumor on one or two of the parathyroid glands. Removing those glands, and leaving the other normal glands behind, cures the disease.

Sometimes, all four parathyroid glands are diseased, and we need to remove three parathyroid glands and part of the fourth during the operation. We never want to remove all four parathyroid glands, because you do need some parathyroid hormone to keep your calcium in normal range.

There are no medications that cure primary hyperparathyroidism. There are medications that can help bring your calcium levels down if they are extremely high, but this is a temporary measure and should be followed up with surgery when possible.

Dr. Boone performing a parathyroid operation.

What We Do: Minimally Invasive Direct Visualization of All Parathyroids

Dr. Boone directly examines all four parathyroid glands in nearly every patient. This is done through a minimally invasive approach with a 1-inch skin incision at the base of the neck. Direct visualization, seeing all of the glands in the operating room, is the best way to ensure that the diseased glands are removed and the remaining glands are healthy. There is no substitute for actually visualizing all of the glands.

Unfortunately, this is not how most parathyroid operations are done. Most parathyroid operations today are "focused" or single-gland operations, in which the surgeon only looks at and removes the one parathyroid gland seen on a preoperative scan. Many patients just have one diseased parathyroid, but up to 30% have multiple diseased glands, and they will not be cured with a focused operation. Surgeons often prefer to do focused operations because they are not experienced in four-gland operations, and were never taught how to find and evaluate the parathyroid glands. This was true for Dr. Boone in training - she was only taught to do focused parathyroid operations. Now, after performing thousands of four-gland parathyroid operations, she only rarely recommends a focused operation. Most patients are better served by having all four parathyroids seen, if the surgeon has the experience to do this quickly and safely.

When having surgery at our center, you will speak with Dr. Boone in the preoperative area to go over the plan and discuss any concerns. She will give you the postoperative instructions and review these with you. The operation lasts about a half hour and is done as an outpatient procedure. After the operation, Dr. Boone will update your family, and once you are awake she will go over the findings with you as well. Most people can go home or back to the hotel within about 2 hours after the procedure. You cannot drive yourself home, so you will need a friend or family member to help. If you are coming from out of town, we prefer that you stay in the Phoenix area the night of surgery. You can fly or drive home the next day. Dr. Boone calls every patient the evening of surgery, to say hi and ask if you have any issues or questions. You will also be given her cell phone number and email address in case you have any questions later.

Questions from Patients (answered by Dr. Boone at Ask a Question

Approaches to Parathyroid Surgery

Surgeons have different ways of doing parathyroid operations. We will cover the most common approaches here, along with the benefits and risks of each, and when you might want to use them.

Open vs. "minimally invasive"?

When you read about parathyroid surgery, you may see it described in various ways, and the terminology can be confusing.

With regard to parathyroid surgery, the terms open and minimally invasive do not have a concrete definitions. It usually refers to incision size - if the incision is small, it is called minimally invasive, and if the incision is large, it is called open. Most parathyroid operations are "minimally invasive" because they can be done through small (1 to 2 inch) neck incisions, even if both sides of the neck are opened during a four-gland operation.

Note about risks: All operations have risks. We operate when we believe that the benefits of surgery outweight the risks of the operation. The risks of parathyroid surgery generally are minimal, but are not zero. All of the surgical approaches listed below have the potential for complications. The risk of complications is not correlated with the surgical approach, but with the surgeon's level of experience. To give yourself the best chance of a good outcome, choose the surgeon with the most experience.

1. Direct Visualization of All Parathyroids

In this method, the surgeon opens the neck and examines all four parathyroid glands, two on each side. This is usually done through a minimally invasive (1 inch) incision. This method will fully expose the thyroid and surrounding structures in the neck. Since many patients (about 30%, and more in older patients) will have multiple parathyroid glands involved, this is a good method of viewing all of the glands together and determining which need to be removed. This can be done through a 1 to 1.5 inch neck incision in most people. When all four glands have been seen, or a thorough attempt has been made to see all four, and the abnormal glands have been removed, the operation is concluded.

Risks of four-gland approach:

2. Focused parathyroidectomy

Since most people with primary hyperparathyroidism will have just one diseased parathyroid gland, some surgeons choose to operate only on one gland. The gland is identified before the operation with an imaging study, such as sestamibi, CT, or ultrasound. The surgeon focuses only on that gland and removes it. The operation is over once that gland is removed.

Benefits of focused parathyroidectomy: Risks of focused parathyroidectomy:

3. Focused parathyroidectomy with intraoperative PTH (ioPTH)

In this method, the surgeon starts out with a focused operation. She uses imaging to guide her to which parathyroid gland needs to be removed. Just before removing the diseased gland and then after, she checks the blood PTH level. If the PTH level drops by a certain amount (usually 50%, and/or into the normal range), the operation is finished. If the PTH does not drop enough, she continues with a four-gland operation. PTH levels generally drop very quickly when a parathyroid tumor has been removed. Theoretically, if there is another tumor present, the PTH will not drop at all or as quickly. For this approach, the operation continues until the PTH drops or the surgeon has exhausted all attempts to get the PTH down.

Benefits of ioPTH-guided focused parathyroidectomy: Risks of ioPTH-guided focused parathyroidectomy:

4. Radioguided parathyroidectomy

Also called Minimally Invasive Radioguided Parathyroidectomy, or MIRP. This is a variation on the above approaches. With this technique, the patient must have an injection of a radioactive tracer like technetium-99 just prior to the operation (usually as part of a sestamibi scan). The parathyroid glands take up the radioactive tracer and are thus temporarily radioactive. The amount of tracer that they take up depends on how active they are (and therefore how diseased they are), so a parathyroid tumor will have a higher radioactivity level than a normal gland.
One thing to note is that radioactivity cannot be measured while the gland is still in the neck, because there is too much background radioactivity from the thyroid (the thyroid also takes up the radioactive tracer). It can only be measured once the gland (or part of the gland) has been removed. The surgeon can take a biopsy of gland (cut off a tiny piece) and measure the radioactivity level. If the level is low, the gland is likely normal. If it is high, the gland is more active than it should be. This can help the surgeon determine whether the gland is diseased, particularly in cases in which the gland is not clearly normal or abnormal. The operation is concluded when all four glands have been evaluated.

Benefits of radioguided parathyroidectomy: Risks of radioguided parathyroidectomy:

5. Scarless parathyroidectomy

This is called scarless because there is no neck scar. Incisions are made in other places and then the surgeon tunnels under the skin and muscle to get to the base of the neck. Given the amount of dissection, it is hard to call this minimally invasive. Despite not having a scar on your neck, there is a lot of internal scarring produced. There are a couple of ways to get to the parathyroids: surgeons can make an incision in either the axilla (armpit) or inside the lower lip. If going through the axilla, the surgeon may also make an incision around the nipple (periareolar) and a "robot" is often utilized (the robot is essentially a set of tiny arms controlled by the surgeon). If going through the inside of the bottom lip, it is called a "transoral" approach. Both approaches require the surgeon to tunnel under the skin and muscle, leading to scarring all through the tracts that are created.

Benefits of scarless parathyroidectomy: Risks of scarless parathyroidectomy:

Choosing the right approach

The optimal parathyroid procedure depends on the patient and the surgeon's experience. The operation routinely performed at our center is the Minimally Invasive Direct Visualization of All Parathyroids. This is typically done through a 1 to 1.5 inch incision, and all four parathyroid glands are evaluated. Most operations are less than half an hour. For first-time operations (when the patient has not had prior neck surgery) this is the method that will give the highest chance of cure. We have found numerous parathyroid tumors that would not have been found with a focused approach, because they were never seen on a scan.

There are situations when a focused operation is the best approach. Because finding all four parathyroid glands can be very challenging, surgeons who have minimal experience with this should perform focused operations. If finding the glands could take four hours, then the surgeon is better off just going after the one gland seen on scan.

There are select scenarios when we will perform focused operations at our center:

  1. Young patients. Teenagers and young adults in their 20s with spontaneous primary hyperparathyroidism typically have one adenoma. It is unusual for them to have two tumors. Thus, if a scan shows one tumor, we prefer to just look on one side of the neck. We can remove the tumor and confirm that the other gland on that side is normal - if it is not, then we need to look at all four glands. Doing a unilateral (one-sided) operation reduces the risk of complications and avoids creating scar tissue on the other side.
  2. Reoperative cases. When someone has already had a parathyroidectomy and needs another, it is often not possible to see all of the remaining glands, as they are stuck deep in scar tissue. Doing a lot of dissection to expose them risks injuring nearby structures like the recurrent laryngeal nerves, which control the vocal cords. For reoperative cases in which both sides of the neck have already been opened, we will usually plan to just go after the tumor seen on scan.

We do not use intraoperative PTH at our center. In theory, it provides some reassurance that the person is cured without having to see all four glands. Unfortunately, as discussed above, it is often inaccurate, and we believe its use can lead surgeons to make poor decisions (either digging around more than they should because the PTH took a while to drop, or stopping the operation when another tumor was present because the PTH dropped quickly). In most cases, it also significantly prolongs the operation and time under anesthesia, while surgeons wait for PTH results. For these reasons, we do not recommend the routine use of ioPTH.

Using radioguidance can be helpful in some situations. At the Norman Parathyroid Center, where Dr. Boone started, all operations were performed with radioguidance. When starting out, it was very nice to be able to measure the radioactivity of every parathyroid. As she gained experience, she realized that radioguidance was a crutch, similar to ioPTH, which made the surgeon feel better but added little to no value for the patient. For most patients, it didn't help at all. Once a surgeon is experienced enough to find the parathyroids and has looked at enough to accurately assess them, radioguidance is not necessary. While sestamibi scans are invaluable for planning parathyroid surgery, it is not necessary to perform a separate scan or injection of radioactive material on every patient on the day of surgery.

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