What are the surgical options for hyperparathyroidism?
Parathyroid surgery or parathyroidectomy is the sole most effective treatment method for primary hyperparathyroidism. Hyperparathyroidism usually results from a benign tumour in one or more of the parathyroid glands (parathyroid adenoma), malignant tumour of the parathyroid glands (parathyroid cancer) or over activity of all four parathyroid glands (Parathyroid hyperplasia). However, in more than 95%, cases of hyperparathyroidism are due to a single parathyroid adenoma.
The aim of surgical treatment in hyperparathyroidism is to remove the source that is overproducing parathyroid hormone. So, if one gland is overactive and is responsible for the hyperparathyroidism, then this gland will be removed.
There are two surgical options available for hyperparathyroidism. They are:
- Open parathyroidectomy
- Minimally invasive parathyroid surgery
When the decision is made for parathyroid surgery, localisation tests are performed to identify which gland is hyperactive. Minimally invasive surgery is only an option if the gland is identified pre-operatively. It is not uncommon for the tests to not identify the gland, and if this is the case, then the patient will be offered an open parathyroidectomy.
Open parathyroidectomy is usually done in patients with parathyroid hyperplasia and when a single hyperactive gland has not been detected. It is usually done under general anaesthesia. First, an incision is made in an appropriate skin crease in the neck and the underlying muscles will be divided to expose the parathyroid glands. The diseased parathyroid glands will be then identified and removed. The surgeon does this with great care without damaging the recurrent laryngeal nerves (the nerves supplying your voice box) which lie close to these glands. The divided muscles will be then put back together again and the incision will be closed using sutures.
Minimally invasive parathyroid surgery
Minimally invasive parathyroid surgery is a keyhole surgery commonly done for patients with a single parathyroid adenoma. Before the surgery, your surgeon will run some tests on you to find out the exact location of the adenoma. A tiny keyhole incision of 2cm will be made on your neck directly above the adenoma. Through this incision, the surgeon will then remove the enlarged parathyroid adenoma while making sure that the nearby nerves are not damaged and finally the skin incision will be closed. This surgery is usually carried out under a general anaesthetic.
The benefits of a minimally invasive parathyroid surgery are that it produces only a smaller scar, and the operating time and the hospital stay is reduced. These patients can be discharged from the hospital on the same day after a successful surgery, although in Australia, most patients are observed in hospital overnight. The risk of recurrent laryngeal nerve damage is also reduced compared to an open parathyroidectomy.
However, in a minority of the cases, the keyhole surgery may have to be converted to an open parathyroidectomy if the surgeon is unable to safely locate the parathyroid adenoma.
What are the risks and complications of parathyroid surgery?
Just like any other surgery, parathyroid surgery also carries its risks and complications. These include the following:
- Post-operative haemorrhage
Post-operative bleeding is an early accumulation of blood in your throat. This will add pressure to your wind pipe and cause difficulty in breathing. This can be corrected by another surgery to remove the blood clot and stop further bleeding.
- Damage to recurrent laryngeal nerve
The laryngeal nerve supplies your voice box. So damage to this nerve can result in hoarseness of your voice box, so damage to this nerve can result in hoarseness of your voice. Even though this is mostly temporary, it could be permanent in about 1% to 2% of the cases. Temporary hoarseness of voice will usually recover within just a few days but very rarely may take up to 6 months. If hoarseness does not recover spontaneously even after 6 months, it can be improved with speech therapy or by surgery of your vocal cords. The risk of damaging the recurrent laryngeal nerve is minimal in experienced hands.
Hypocalcaemia is when your blood calcium becomes lower than the normal range. This may occur for various reasons; other parathyroid glands dormant, damage/bruising of the other glands, bones reabsorbing calcium from blood. This is usually temporary, and is managed with oral calcium supplements.
In certain instances, even though the adenoma is excised, hyperparathyroidism can recur if another gland becomes hyperactive.
- Infection of your scar
Wound infection is very rare after a parathyroid surgery and thus the reason for not using antibiotics after the surgery. But if an infection does occur, consult your surgeon for evaluation.
What to expect after the operation?
The surgeon will organise for blood tests on the day of or the day after to confirm that the hyperparathyroidism has resolved.
Arrangements will then be made for an outpatient review in a week’s time to make sure that the patient and wound are recovering well. If all is in order at that stage, another review will be organised in 3-6 months to make sure that the hyperparathyroidism has not recurred.