PARATHYROIDECTOMY – THE PROCEDURE AND THE RISKS
Parathyroidectomy involves removal of one or more abnormal parathyroid glands and is performed for the treatment of hyperparathyroidism. Parathyroidectomy can either be performed as a minimally invasive procedure using a small mini-incision and special instruments to remove a localized abnormal parathyroid gland, or else as an open procedure with a standard incision and technique to search for all the parathyroid glands. Open parathyridectomy is used when localisation studies have not demonstrated a single abnormal gland. Either way, parathyroidectomy is a straightforward procedure usually performed under general anaesthesia, with a supplemental local anaesthetic cervical plexus block to reduce post-operative pain and discomfort. An incision is required. For minimally invasive surgery this is a small mini-incision in a skin crease on the side of the neck or in the midline. For open surgery it is a standard incision placed in a skin crease in order to provide an optimal cosmetic outcome. A hospital stay of either one or two nights is standard.
Any operation carries with it the risk of a complication or unanticipated outcome. General risks of any operation include the possibility of an anaesthetic reaction, bleeding, infection, or thrombosis. There are also clearly a significant number of exceedingly uncommon potential complications which cannot be detailed. The specific risks of parathyroidectomy include:
DAMAGE TO THE RECURRENT LARYNGEAL NERVES: The recurrent laryngeal nerves supply the muscles of the larynx which are responsible for the voice as well as for protecting the airway. These nerves run directly through the operative site and lie against the back of the thyroid gland next to the parathyroid glands. They are often stretched during removal of the parathyroids and may be damaged, or may temporarily lose their function after surgery. Loss of function of one nerve leads to a croaky voice. The risk of this occurring in expert hands is 1% (1 in 100 operations) but may be higher with less experienced surgeons. Loss of function of both nerves is a major issue and may lead to a tracheostomy or a tube in the airway, although the risk of this is exceedingly small at less than 1 in 10,000 cases.
PERSISTENT DISEASE: At surgery every attempt is made to remove all of the abnormal parathyroid glands, however there is no guarantee that they will all have been identified. Minimally invasive parathyroidectomy relies totally upon the accuracy of the pre-operative localizing scan to guide the surgeon as to which parathyroid is removed through the mini-incision. In 2% of cases, despite the scan showing only one abnormal gland, more than one will be present and not all will necessarily be removed at surgery. Thus 1-2% (1 in 50-100 patients) will require 2 operations to cure the disorder. The same situation can even occur in open parathyroidectomy, as abnormal glands can travel to unusual sites such as the base of the heart. Some surgeons use parathyroid hormone monitoring (IOPTH) during surgery however our published data demonstrates that the use of this technique can cause incorrect outcomes and do more harm than good (see FAQ on IOPTHs). Other groups promote radioguided parathyroidectomy with a nuclear probe but this technique has been abandoned by all experienced Australian parathyroid surgeons as a gimmick of little or no value.