What does parathyroid surgery involve?
Surgical procedures of the parathyroid glands depend on the underlying cause of parathyroid disease. There are three common scenarios:
This is where a 2-3cm transverse skin crease incision is made over the side of the neck where the offending gland has been detected on imaging. The gland is removed and sent for analysis during the operation to confirm it is parathyroid tissue. This is done because other lumps, such as lymph nodes, in the neck may look like parathyroid tissue.
The parathyroid hormone (PTH) level is checked after your surgery to confirm that the offending gland has been removed.
When the pre-operative imaging fails to show where the offending gland is, we perform a four-gland exploration. This is usually through a 5-7cm incision in the lower neck through which we explore all four glands to find and remove the abnormal gland(s). Removing half or rarely all of the thyroid gland may be required during this procedure as the abnormal parathyroid gland may be inside the thyroid gland.
The parathyroid hormone (PTH) is checked after your surgery to confirm that the offending gland has been removed.
A subtotal parathyroidectomy refers to removing 3.5 glands leaving half of the most “normal”-looking gland.
A total parathyroidectomy refers to removing all of the parathyroid glands. Part of the most “normal” gland is implanted in the neck, chest or forearm to provide some parathyroid function after surgery.
The procedure
A parathyroidectomy is performed under a general anaesthetic.
A pair of fine needles connected to electrodes are placed just under the skin of your upper arm. These are connected to a machine used to monitor the laryngeal nerves during your operation.
An incision is made over the front of the lower part of the neck along a skin crease if possible. The incision is 2-3cm for a minimally invasive parathyroidectomy (MIP) or 5-7cm long for an exploration, a sub-total or total parathyroidectomy or if a thyroidectomy is performed at the same time.
The parathyroid gland is removed by dividing its blood vessels taking care to prevent injury to the nerves. This may involve the placement of metal clips inside the neck to seal some of the blood vessels. These are titanium clips and they do not set off metal detectors (eg. at airport security). They are also MRI-safe.
In the case of operating on all parathyroid glands, a search for abnormal glands proceeds in a systematic fashion exploring the possible areas that parathyroid glands can be located in or migrate to. Removing part of the thyroid gland (lobectomy) may be rarely be performed in the case of a missing parathyroid gland.
You may have a drain to collect blood / fluid after the operation.
The incision is closed with dissolving sutures and dressed with Steristrips which are waterproof.
What are the risks of surgery?
Surgical procedural risks can be divided into anaesthetic and surgical risks.
Anaesthetic risks are usually discussed with the patient by the anaesthetic team.
Surgical risks specific to parathyroid surgery include:
- Nerve injury – The risk of permanent damage to the recurrent laryngeal nerve (RLN) is less than 1%. The risk of temporary paralysis is about 7% with full recovery by 6 months. Injury to one of the nerves may result in a weak husky voice. Injury to the RLN nerve on both sides is thankfully extremely rare (1 in 10,000) but results in closure of both vocal cords. This may require a tube to be put into the trachea through a hole in the neck (tracheostomy) at least as a temporary measure.
- Reduced parathyroid function – Following a four-gland exploration, the glands explored but not removed may be damaged by the exploration which can result in temporary or permanent reduction in parathyroid function.
- A drop in parathyroid function causes a drop in your blood calcium levels which may manifest as tingling around the lips, in the fingers or toes. You should report these symptoms to your nurse as soon as possible or to your doctor if you notice these after discharge. A drop in calcium is a medical emergency that may result in serious cardiac arrhythmias if left untreated.
- Your parathyroid function is checked after surgery with a blood test. If there is a drop in function, you will be started on calcium tablets and calcitriol which is a special form of vitamin D. You will require frequent blood tests until your parathyroid function returns to normal.
- If you continue to have a drop in your parathyroid function more than six months after surgery, this drop is likely to be permanent and you will need to be on calcium and calcitriol indefinitely.
- Failure to find the offending gland – Despite extensive neck exploration, the offending gland may remain missing. Thankfully, this is rare. Further investigations and repeat imaging will be required before considering further surgery.
- Bleeding – Bleeding post parathyroid surgery is unlikely but is a serious complication as it can affect the airway. The risk is highest in the first 12 hours which is why you are admitted to hospital after your surgery. If you have any neck swelling or difficulty breathing, you should report this to your nurse immediately.
- A post-operative bleed may occur even one week after surgery. You should avoid straining / shouting / lifting for the first week to reduce this risk.
- If experience neck swelling or difficulty breathing after discharge, you should call an ambulance or go to the nearest emergency department as soon as possible.
- Infection – the risk of infection post pararthyroid surgery is very small.
Before surgery
Fast from midnight for a morning procedure OR from 7am for an afternoon procedure.
You will be contacted by the hospital the day before your procedure to let you know what time to come in. This is usually 1-2 hours before your procedure to allow for the hospital check-in procedures.
You may require a vocal cord check before surgery. If this is the case, it will be organized some time before surgery. It involves doing a nasoendoscopy where a thin flexible tube with a camera is inserted into the nose to inspect the vocal cords to ensure they are working normally. This is especially important if you have had thyroid or parathyroid surgery in the past.
After surgery
Take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).
Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.
Stronger pain killers such as opioid anaelgesics (Endone, Codeine) should be taken sparingly as they can cause constipation which results in more straining.
Once you are awake from the anaesthetic, you can have a normal diet as tolerated. You start with sips of water, clear fluids, then to a diet.
If a thyroid lobectomy is performed, 20% of patients may require Thyroxine. You will not be started on this straight away but will have a blood test in six weeks. If your thyroid function is reduced, you will be started on Thyroxine.
- As described above, you may have reduced parathyroid function with a low calcium
- You may experience tingling around the lips, tips of your fingers or toes. If you experience this at home:
- You should take 3 Caltrate tablets as soon as possible (can be found in any pharmacy over the counter)
- Go to the emergency department or your local doctor as soon as possible.
- Contact our office or after-hours emergency number.
- You may require calcium and calcitriol tablets if your parathyroid function is reduced to prevent a low calcium level (see above).
- Calcium management is more complicated in patients with kidney failure and will be co-ordinated by your renal physician or endocrinologist.
Your wound is dressed with Steristrips only.
These are waterproof so you can shower but cannot swim or have a bath for 2 weeks or until after your follow up wound review.
Keep the Steristrips on for 1-2 weeks.
You should avoid straining for 1 week as this can increase the chance of post-operative bleeding.
Following MIP, you are admitted overnight and can usually go home the next day.
Following any procedure on all parathyroid glands, you are admitted overnight. Duration of stay depends on the function of the remaining parathyroid glands based on a blood test.
You will be seen 1-2 weeks after surgery for a wound check and to discuss your pathology results.
The appointment is usually made for you before leaving the hospital.