Parathyroidectomy: Indications, Preoperative Preparation, Procedure

PARATHYROIDECTOMY SUYASH VERMA (5318134) MODERATOR:-Dr. VARINDER PAUL

INDICATIONS IN PRIMARY HPT Symptomatic HPT Asymptomatic HPT with criteria for surgical interventions are:- Raised in serum calcium level (more then 1 mg/dl of upper limit) 24 hour urinary calcium if more then 400 mg Bone density greater than 2.5 standard deviations below peak bone mass in lumbar spine/hip/lower end of radius Age below 50 years When medical therapy is not possible 2

INDICATIONS IN SECONDARY HPT Here indication for removal of all four glands with auto- transplantation of parathyroid is only in severe cases or with renal osteodystrophy 3

PREOPERATIVE PREPARATION Vocal cords should be assessed by preoperative indirect laryngoscopy High calcium level treated with hydration diuresis steroids (prednisolone) phosphate infusion calcitonin (subcutaneous injection) Diphosphonate etiodronate disodium mithramycin 4

ANAESTHESIA AND POSITION General anesthesia is used with neck hyperextension by placing rolled sheet under the shoulder blades Head Is placed on the head ring Head end of the table is raised to semi- erect position(semi- Fowler position) 5

INSCISION AND DISSECTION Collar incision : 2 finger breadth above the suprasternal notch or 1 cm below the cricoid cartilage From one sternocleidomastoid to the other Subplatysmal flaps are raised superiorly till thyroid cartilage and inferiorly till suprasternal notch Strap muscles separated after opening the deep fascia in the midline Thyroid gland is mobilized to identify the parathyroid having adenoma and it is mobilized End artery of parathyroid is identified and ligated Adenoma is separated from adjacent thyroid tissue using gauze dissection Parathyroid may be confirmed by frozen section biopsy or by table aspiration ( PTH assay > 1500 pg/mL confirms removed tissue ) 6

DISSECTION Parathyroid may be confirmed by frozen section biopsy or by table aspiration ( PTH assay > 1500 pg/mL confirms removed tissue ) In parathyroid hyperplasia all 4 glands are removed and one third of one gland is auto transplanted into the brachioradialis or sternocleidomastoid with marker stitch ( around 18 pieces 1 mm each ) Wound is closed with proper haemostasis. 7

COMPLICATIONS Haemorrhage recurrent nerve palsy Permanent hypoparathyroidism Persistent hyperparathyroidism 5% Recurrent hyperparathyroidism ( hypercalcemia reoccurs 12 months after 1stsurgery) Additional thyroidectomy may be required Injury to esophagus may occur Hungry bone syndrome : increased calcium uptake by bones after causes sudden drop in calcium levels . Requires monitoring Calcitriol and calcium supplementation required 8

EFFECTS OF SURGERY Neuromuscular symptoms : proximal muscle weakness responds better than respiratory muscles Psychiatric illness and depression improve Hip and lumbar spine bone mineral density improves Nephrocalcinosis improves Operative failure rate is 1.5 to 6 % Radio guided parathyroidectomy using IV technicum99 sestamibi 2 hour before surgery is helpful for appropriate adenoma removal. Gamma camera is used intraoperatively 9

SURGICAL APPROACHES Classical approach ( traditional approach ) Minimally invasive parathyroidectomy (focused parathyroidectomy) Video assisted Endoscopic parathyroidectomy Median sternotomy Remedial parathyroidectomy Subtotal parathyroidectomy Total parathyroidectomy with parathyroid auto transplantation 10

THANK YOU 11