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Parathyroid Surgery: The Standard Technique

Overview of Parathyroid Surgery

Since 1925, the gold standard treatment for primary hyperparathyroidism has been to surgically remove the parathyroid gland (or glands) that are overproducing hormone. Remember, this is a hormone problem, so the goal is to remove the source of the excess hormone (remove the bad parathyroid gland, leave the normal parathyroid glands). The standard parathyroid operation has not changed since its invention in 1925. It is performed by putting the patient to sleep under general anesthesia, an incision is made in the neck and the thyroid gland is mobilized to allow the surgeon to identify the 4 parathyroid glands, which reside moderately deep in the neck behind the thyroid. Patients are typically hospitalized overnight, and occasionally as long as a day or two. The incision has to be made of sufficient length to allow the surgeon adequate exposure of the numerous important structures in the neck, and thus it is typically 5 to 7 (or even 10) inches long. These wounds eventually heal quite nicely. 

Because of the numerous small nerves and other important structures within the neck that reside around the parathyroid glands, this standard parathyroid operation can be technically challenging and is usually only performed by experienced endocrine surgeons or surgeons with extensive head and neck operative experience. Numerous publications in medical journals have shown that the success rate following parathyroid surgery is directly related to the number of parathyroid operations the surgeon has performed. 

During this operation, the surgeon must identify all 4 parathyroid glands and remove whichever one(s) is enlarged. As covered in the section describing hyperparathyroidism in detail, approximately 96% of the time there is one large parathyroid gland (an adenoma) and 3 normal parathyroid glands. In this situation, the one large gland (the parathyroid adenoma) would be removed, leaving the 3 normal ones to function in a normal fashion indefinitely.

If the surgeon found all 4 parathyroid glands to be enlarged (called: parathyroid hyperplasia), he or she would typically take out 3 or 3 1/2 of these glands, leaving some parathyroid tissue behind to function normally in the future. In experienced hands, this operation has a cure rate of about 94%, but it can be as low as 85% for surgeons who operate on parathyroid patients infrequently.

To complete a standard parathyroid operation safely with a high rate of success, the surgeon operates on both sides of the neck (a standard bilateral neck exploration) and is always performed using general anesthesia.

General anesthesia is extremely safe for nearly all patients. Because of the concern over general anesthesia in some elderly patients, and concerns about a 6 to 8 in incision on the neck and the risks of damage to the nerves to the voice box, some endocrinologists and family doctors elect not to send patients for this operation until the patients develop hyperparathyroid symptoms or have a significant loss of bone density (osteoporosis).

This means of management of parathyroid disease may or may not be in the best interests of the patient based upon the potential risks (small, but real) of the standard parathyroid operation. You need to discuss the pros and cons of this safe and routine operation with your endocrinologist and weigh the risks of surgery versus continued monitoring of your body's calcium stores and your bone density.

Overview of Standard Parathyroid Surgery For Primary Hyperparathyroidism

  • You have 4 parathyroids, so all 4 are examined to see which ones are over-producing hormone.
  • If one bad (overactive) parathyroid found, it is removed.
  • If 4 overactive glands are found, 3 or 3 1/2 are removed.
  • High rate of cure is the norm (~94%) for experienced endocrine (parathyroid) surgeons, but it can be as low as 85% for general surgeons who perform parathyroid surgery only a few times per year.
  • Cure rates are extremely dependent upon the experience of the surgeon.
  • Requires general anesthesia (extremely safe).
  • Risks are very low (~1% chance of injury to the nerve to the voice box).
  • Complication rates are extremely dependant upon the experience of the surgeon.
  • Expected blood loss is extremely low (less than 1/4 cup, so no need to prepare for possible transfusions)

EDITOR'S NOTE:   The standard operation for parathyroid disease as discussed on this page is no longer the preferred method of removing parathyroid glands for patients with primary hyperparathyroidism. It is a very safe and effective operation, but typically is a much larger and more complex operation than is needed for most patients. 

Since the invention of minimally invasive radioguided parathyroid surgery in 1995, many universities in the US and around the world have documented that minimal parathyroid surgery has a cure rate that is higher, a complication rate that is less than half of the standard way (near zero), and it can be done with local anesthesia typically in less than 20 minutes.  There are several pages on minimal parathyroid surgery on EndocrineWeb, including surveys from endocrinologists and summaries of journal articles showing statistical evidence of the benefit of minimal parathyroid surgery. Before you have surgery, make sure you understand your options.