Types of Parathyroid Surgery
The two main types of parathyroid surgery are:
- Focused parathyroidectomy – In this technique, the surgeon identifies the location of the diseased parathyroid gland(s) with localization studies before the operation and then during the operation goes right after just the diseased gland(s). See Localization ».
- Bilateral neck exploration – In this technique, the surgeon explores both sides of the neck to look at all four parathyroid glands. The surgeon then decides which parathyroid gland(s) to remove based on the size, color, and texture of the parathyroids.
Focused parathyroidectomy and bilateral neck exploration each have advantages and disadvantages, but both are effective when done by a surgeon highly experienced with each approach. Most parathyroid surgery done at the New York Parathyroid Center is done as a focused parathyroidectomy. There are many different techniques that can be used to help remove the diseased parathyroid gland(s) including radioguided-parathyroidectomy (using a radioactive tracer and a handheld Geiger counter to identify diseased gland) and video-assisted parathyroidectomy (using a camera and special instruments to identify and remove the diseased gland). However, for the vast majority of cases, these techniques are not necessary. During the operation, the surgeon will usually confirm that all of the diseased parathyroid tissue has been removed by checking the intraoperative PTH levels. Regardless of the type of surgery, New York Parathyroid Center surgeons are almost always able to do the operation as a minimally invasive parathyroid surgery.
Minimally Invasive Parathyroid Surgery
The typical incision made for parathyroid surgery is known as a "collar incision" in which a large incision (around 5 to 6 inches) is made stretching from one side of the neck to the other just above the collarbone. Minimally invasive parathyroid surgery refers to certain types of surgery in which the parathyroid is removed through very small incisions (around 1 to 1½ inches) using special techniques. New York Parathyroid Center surgeons perform minimally invasive parathyroid surgery in over 97% of patients. In addition to using very small incisions, our surgeons "hide" the incision in a natural skin crease, which acts like camouflage. Most people will not be able to notice the incision once the redness fades away. See our Scar Gallery for examples of minimally invasive parathyroid surgery. At the New York Parathyroid Center, 95% of our patients are able to go home after a 4-hour observation period in the recovery room. In certain cases, a patient may be asked to spend the night in the hospital. Patients who spend the night in the hospital are typically discharged by 10AM the next morning.
There will often be a little swelling around the incision site for a few weeks after the operation. A small amount of swelling is part of the normal healing process. The natural reaction to surgery is to form scar tissue that will become firmer in the first few weeks and then will slowly soften up. This swelling is typically only 1 to 2 finger breadths in size and should not get significantly bigger. If the swelling continues to get bigger, especially if it is growing quickly over a couple of hours, contact your surgeon immediately. Over the next few months, the swelling and scar tissue will disappear and the area should look and feel just like the normal skin.
Choices of Anesthesia
There are two main choices for anesthesia during parathyroid surgery: general and local anesthesia. Parathyroid surgery is most commonly performed with general anesthesia, but centers specializing in parathyroid surgery may also offer the choice of local anesthesia. Dr. Paul Logerfo, the co-founder of the New York Parathyroid Center, was one of the pioneers and creators of the local anesthesia approach to parathyroid surgery and this technique is routinely employed at our Center. At the New York Parathyroid Center, the surgeon works with each individual patient to decide which type of anesthesia is right for him or her.
With both anesthesia techniques the surgeon will perform a cervical nerve block to numb up the neck so that the patient does not feel sharp pain during the operation. This block lasts about 6 to 8 hours, which also helps reduce the amount of pain the patient has after the operation. With local anesthesia, the patient is given light sedation through the IV, which is similar to the "twilight" anesthesia people often have with colonoscopy. Typically patients will be napping throughout the operation and will be woken up when it is over. With the general anesthesia, the patient is given a slightly larger dose of medicine and a breathing tube is placed. The breathing tube is removed and the patient is woken up once the operation is over. Since the cervical nerve block does such a good job with pain control, the anesthesiologist gives much less medication for the general anesthesia then they normally would have to. For this reason, the amount of post-operative nausea and time to recover from anesthesia is about the same with both the general and local anesthesia.
Intraoperative PTH Monitoring
The parathyroid glands make parathyroid hormone (i.e. PTH). PTH levels in the blood change very quickly because the hormone can be cleared from the blood within minutes. Surgeons use this fact to confirm that all diseased parathyroid tissue has been removed by measuring the PTH levels at certain times during an operation in a procedure called intraoperative PTH monitoring. In the most common form of intraoperative PTH monitoring, the surgeon measures the PTH level before starting the operation (i.e. baseline), before tying off the blood supply to the diseased parathyroid gland (i.e. pre-excision or time zero), and then 5 and 10 minutes after removing the diseased parathyroid gland. Ten minutes after removing the diseased parathyroid gland, the PTH levels should drop by 50% or more (i.e. should drop by more than half) from the higher of the baseline or pre-excision PTH level. If the levels fall by more than 50%, then there is an approximately 98% chance that the patient is cured. If the levels do not fall by more than 50%, then there may be other diseased parathyroid glands and the surgeon will usually look at the other 3 glands through the same small incision and make a decision about which one(s) to remove based on how abnormal they look.
Intraoperative PTH levels from successful parathyroid operation
PTH levels fell by more than 50% (i.e. from 150 to 40 and are in the normal range at 10 minutes after removing the diseased parathyroid
Intraoperative PTH levels from successful parathyroid operation after removal of two parathyroid glands
PTH levels fell by more than 50% (i.e. from 150 to 35 and are in the normal range at 10 minutes after removing the diseased parathyroid
Autotransplantation is a special technique in which parathyroid tissue is removed from its normal location and then placed into the muscle of the neck or forearm. The autotransplanted parathyroid gland then lives and functions in the new location. Autotransplantation is typically performed if:
- the parathyroid gland that is removed is the patient's last parathyroid (i.e. the patient has had a previous operation in which 3 parathyroid glands were removed),
- the patient has 4 hyperactive parathyroid glands (i.e. four gland hyperplasia) and all 4 glands need to be removed, and
- a normal parathyroid gland has been removed.
If the autotransplanted parathyroid is a normal parathyroid gland, it is often put in one of the neck muscles. If the autotransplanted parathyroid is a hyperactive parathyroid gland, it is often put in the forearm muscle because if the hyperactive autotransplant grows or becomes too active again, it is easier and safer to remove it from the forearm than the neck. The autotransplanted parathyroid gland takes about 4 to 6 weeks to start working again and during this time patients will need to take calcium supplements (typically pills, but sometimes intravenous or IV) and calcitriol (vitamin D).
Having the equivalent of at least one normal-sized or functioning parathyroid gland is critical to maintaining the calcium levels in the body. If there is no functioning parathyroid tissue, hypocalcemia (i.e. low calcium levels) can occur and will require calcium and vitamin D supplements. In certain cases, the surgeon can freeze and save some of the parathyroid tissue that is removed in a process called cryopreservation. This frozen parathyroid tissue is then stored in the freezer under sterile conditions as an insurance policy. If the patient ever needs more parathyroid tissue in the future, the surgeon can thaw it out and autotransplant it (i.e. place it surgically) in the muscle, usually the forearm. Since the body only needs one normally functioning parathyroid gland, cryopreservation is not necessary for every patient having parathyroid surgery, especially in routine cases. In fact, cryopreservation is typically only done for patients with multiple abnormal glands or who are having re-operative surgery (i.e. a second or third parathyroid operation). Cryopreservation requires specialized equipment and skills to perform and not every institution will provide this service. The New York Parathyroid Center offers state of the art cryopreservation facilities and techniques to provide the most comprehensive care to patients with parathyroid disease.
In the hands of an experienced parathyroid surgeon, parathyroid surgery is a safe procedure with few complications. The main risks of parathyroid surgery include:
- Bleeding in the neck: As with any operation, there is always a chance of bleeding. The average blood loss for this operation is less than a tablespoon and the chance of needing a blood transfusion is extremely rare. However, bleeding in the neck is potentially life threatening because as the blood pools, it can push on the windpipe or trachea causing difficulty breathing. In the hands of New York Parathyroid Center surgeons, the risk of bleeding is less than 1%. However, due to this rare risk of bleeding, patients are observed for 4 hours by our highly trained recovery room staff. If there is no sign of bleeding and the patient feels well, he or she may go home. Once at home, patients and their friends/family should watch for signs such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon. There will often be a little swelling around the incision site for a few weeks after the operation. A small amount of swelling is part of the normal healing process. The natural reaction to surgery is to form scar tissue that will become firmer in the first few weeks and then will slowly soften up. This swelling is typically only 1 to 2 finger breadths in size and should not get significantly bigger. If the swelling continues to get bigger, especially if it is growing quickly over a couple of hours, contact your surgeon immediately. Over the next few months, the swelling and scar tissue will disappear and the area should look and feel just like the normal skin.
- Hoarseness (Recurrent laryngeal nerve injury): There are two nerves called the recurrent laryngeal nerves that run just behind the parathyroid. These nerves control the vocal cords. If one of these nerves is injured, the voice may become hoarse. In the hands of our New York Parathyroid Center surgeons, the chance of having a temporary hoarseness is 3% and the chance of having a permanent hoarseness is less than 1%. Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve or fix the voice.
- Hypocalcemia (Hypoparathyroidism): After parathyroid surgery, there is a small chance that the blood calcium levels can become lower than normal, a situation called hypocalcemia. This typically only happens if a person has 4 hyperactive glands and the patient has 3 to 3.5 of the glands removed. In some cases, the diseased parathyroid gland(s) that is removed has suppressed or temporarily shut down the other parathyroid glands. Hypocalcemia can cause symptoms such as numbness and tingling (especially around the lips and in the hands and feet) as well as cramping and even "locking" of the hands and feet. In the hands of New York Parathyroid Center surgeons, the risk of having a temporarily low blood calcium level is about 5% and the risk of having a permanently low blood calcium level is less than 1%. It is important to note that numbness and tingling may be caused by something other than a parathyroid problem. If a patient has symptoms caused by low blood calcium, the surgeon may prescribe extra calcium and a vitamin D supplements.
Other risks of parathyroid surgery include wound infections and seromas, which is collection of fluid under the incision. Wound infections happen in about 1 out of 2000 operations (far less than 1%) and because of this low risk, the routine use of antibiotics is not needed. Seromas happen rarely and usually disappear within a few weeks. If the seroma is large, the surgeon may drain it with a small needle. The risk of having any of these complications depends on the experience of the surgeon. Although the risk of these complications cannot be eliminated entirely, they can be minimized in the hands of an experienced parathyroid surgeon. See Finding a Surgeon ».
Preparing for Surgery
In addition to the localizing tests that are designed to identify the diseased parathyroid gland(s), prior to the operation, patients will need certain pre-operative testing to make sure that they are healthy enough and properly prepared for an operation. The typical recommendations for pre-operative testing include:
- Blood tests done within 30 days of the operation
- CBC (complete blood count)
- BMP (basic metabolic profile)
- B-HCG (blood pregnancy test) for women
- Coagulation profile (especially if the patient is on blood thinners or has a bleeding disorder)
- EKG done within 3 months of the operation for men and women older than 40
- Chest X-ray done within 6 months of the operation for men older than 50 and women older than 60
In addition, patients may require additional tests in certain situations to help plan the operation. It is not common to need these additional tests, but they may include:
- Fiberoptic laryngoscopy: This test allows the surgeon to look at how well the vocal cords are moving by passing a thin flexible camera through the nose into the airway. This test is used in patients with hoarseness, a previous neck operation, or cases of advanced cancer.
Patients with other significant medical issues may be asked to visit with their medical team to obtain a letter of medical clearance. The medical clearance allows the patient's medical team the opportunity to optimize the patient's health prior to an operation and allow the specialists to make recommendations for how best to care for the patient's other medical issues during the peri-operative period.
In general, patients should be eating, drinking, walking around, and doing their normal activities the night of the operation. However, patients will be asked to do no heavy lifting, swimming, or soaking in a bathtub for 1 week after the operation. Patients should call their surgeon's office to make a follow up appointment approximately 2 to 3 weeks after surgery.
Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Some people experience a dull ache, while others feel a sharp pain. The Parathyroid Center recommends taking Tylenol, Motrin, or Advil as the bottle directs around the clock for the first few days (as long as the patient's overall health allows it). Patients will be sent home with a prescription for a mild narcotic medication, but many patients do not need to use it. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days.
The incision is covered with a protective strip of clear glue called collodion. The collodion will turn white and start curling up at the edges in about 7 to 10 days. When this happens, it can be peeled off or one can wait until it falls off on its own. If there is itching once the collodion comes off, lotion can be applied to the scar. If the patient is going out into the sun, we recommend putting sunscreen or sunblock on the incision so that it tans evenly. Patients may apply whatever they like to the incision as long as it does not irritate the skin. In general, most patients do nothing and the cosmetic results are excellent. Patients can shower the day after the operation, but do not soak or scrub the incision. After showering, use a cool hair dryer to dry the incision. There may be bruising around the incision or upper chest and slight swelling above the scar when sitting up or standing. In addition, the scar may become pink and hard. This hardening is part of the normal healing process, will peak at about 3 weeks and may result in some tightness or difficulty swallowing, which will disappear over the next 2 to 3 months.
Bleeding is a rare complication and those few patients who do have a bleeding problem almost always have it during the 4-hour observation period in the recovery room. However, in the first 24 to 48 hours, patients and their family/friends should observe the incision and neck for signs of bleeding in the neck such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.
In general, patients may resume taking their normal medications the day after the operation. The exceptions are blood thinners, aspirin, and Plavix. Patients should discuss with their doctors when and if they should restart these medications. Typically, patients will be given prescriptions for two medications after the operation:
- Pain medication: A mild narcotic medication will be prescribed. We recommend trying non-narcotic medications like Tylenol, Motrin, or Advil first and if the patient is still having pain, then trying the narcotic medication.
- Calcium: All New York Parathyroid Center patients will be sent home with a prescription for calcium pills. This calcium prescription is to help prevent patients from having symptoms of low blood calcium levels. Patients will be asked to take calcium as follows: Calcium 1000 mg every 6 hours for 7 days after the operation, followed by Calcium 500 mg every 12 hours until they are seen in the office 3 weeks later.
Most patients (97%) have no problems with their voice immediately after the operation. Rarely, a patient may have temporary changes in the voice such as fluctuations in volume and clarity (hoarseness). In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. Hoarseness generally improves within the first 3 to 4 weeks after the operation but it may take up to 6 months. Patients should not be worried about hurting their voice by talking. If the voice is still hoarse after 3 to 6 months, the surgeon may prescribe voice-strengthening exercises or ask the patient to visit with a voice specialist for evaluation.
In about 5% of patients who have parathyroid surgery, the parathyroid glands may become stunned. This stunning causes the blood calcium levels to drop below normal (i.e. hypocalcemia). Symptoms of hypocalcemia include numbness and tingling in your hands, soles of your feet and around your lips. Some patients experience a "crawling" sensation in the skin, muscle cramps or headaches. These symptoms appear between 24 and 48 hours after surgery. It is rare for them to appear after 72 hours.
In order to avoid the symptoms of hypocalcemia, New York Parathyroid Center surgeons prescribe calcium post-operatively for all patients having parathyroid surgery. If patients are still having symptoms after taking the calcium as prescribed, they should take an extra 1000 mg of calcium. If the symptoms do not improve after 30 minutes, they should call their surgeon. At this point, the surgeon may prescribe a form of vitamin D called Calcitriol or Rocaltrol. This medication helps the body absorb more calcium.
Vitamin D deficiency can lead to temporary hypocalcemia (i.e. calcium levels that are too low) after successful parathyroid surgery but may also lead to issues like kidney stones and very high calcium levels if the deficiency is corrected too fast before the operation. For this reason, it is important that patients seek the advice of parathyroid experts to find a safe way to bring their vitamin D levels back to normal.
If you are dealing with a parathyroid issue, our team at the Columbia Parathyroid Center is here to help. Call (212) 305-0444 or request an appointment online.