After evaluation in clinic, the patient and the endocrine surgeon may plan surgical intervention. On arrival at the hospital on the day of surgery, the endocrine surgeon will see the patient. This time provides the patient an opportunity to review the benefits, risks and options of the procedure discussed at the pre-operative clinical visit. The patient may have general anesthesia or some patients may do well with sedation and local anesthetic. The operation lasts approximately 90 minutes to 2 or 3 hours depending on the anatomic findings.
At the University of Virginia, we use “minimally invasive” techniques when appropriate for the patient. This involves imaging studies such as ultrasound or CT that are done before the operation to locate the source of the disease, using minimal incisions, and checking hormone levels during the operation to determine if the high hormone level has been adequately treated. We selectively discharge appropriate patients on the same day as surgery, and almost everybody is discharged within 24 hours of surgery.
The primary risk of surgery is failure to find the parathyroid adenoma. Any experienced endocrine surgeon should expect a 95 to 98% success rate in appropriately selected patients with primary hyperparathyroidism. This, however, is not 100%. Occasionally, parathyroid adenomas exist in what are called “ectopic” positions. Such parathyroid adenomas, because of their embryologic origins, can be in unusual places in the neck as well as in the area behind the sternum (mediastinum). Such parathyroid adenomas are unusual but occur in one to three percent of cases. In some of these cases, the preoperative imaging studies may be misleading. Ultimately, if the surgeon is unable to find the adenoma within the neck, he or she will most likely terminate the operation. Upon recovery, monitoring of the serum calcium levels will be done over the next several months. If the levels continue to be elevated, specialized tests including sestamibi scan, CT or MRI scanning may be performed in an attempt to find the adenoma. Continued elevated calcium levels may well require a second surgery.
Another recognized complication of parathyroid surgery is the possibility of recurrent laryngeal nerve damage which results in voice hoarseness. In experienced hands this should occur less than 1% of the time; however the recurrent laryngeal nerves run immediately adjacent to the parathyroids and injury has been known to occur. If one or both nerves are damaged significant hoarseness can result. This is an especially important consideration in patients undergoing a second or reoperative neck exploration for parathyroid disease since scarring puts the nerves at greater risk.
Research has proven that the likelihood of having a safe and successful parathyroid surgery is improved by having an experienced parathyroid surgeon. A surgeon should perform more than 50 parathyroid operations per year to be considered an expert. At the University of Virginia, Dr. Hanks and Dr. Smith both have performed approximately 120 parathyroid operations in the prior year.
If you desire further information regarding hyperparathyroidism or parathyroid surgery, we recommend reviewing the “Parathyroid Gland” portion of the American Association of Endocrine Surgeons (AAES) Patient Education Site. Patients may find that many websites offer confusing or conflicting information regarding parathyroid disorders. The AAES site offers reliable information.