University of Virginia Health System

After evaluation in clinic, the patient and the endocrine surgeon may plan surgical intervention. On arrival at the hospital on the day of surgery, the endocrine surgeon will see the patient. This time provides the patient an opportunity to review the benefits, risks and options of the procedure discussed at the pre-operative clinical visit. The patient will usually have general anesthesia. The operation lasts 90 minutes to 2 or 3 hours depending on the anatomic findings. At the University of Virginia, we have the capability of employing preoperative localization or "minimally invasive" surgery. This is an evolving technology that we are using for selected patients at this time. We have a 95% success rate with general anesthesia and the standard bilateral exploration. Interestingly, we employ essentially the same 1 - 1.5 centimenter incision which is described for that procedure. We have not concluded that current data shows cost savings in employing minimally invasive surgery. We do use the techniques of "minimally invasive" surgery for patients who have had previous unsuccessful neck exploration for parathyroid adenomas. We have selectively discharged patients on the same day as surgery. The remainder of patients who are hospitalized are discharged within 24 hours of surgery.

The primary risk of surgery is failure to find the parathyroid adenoma. Any experienced endocrine surgeon should expect a 95 to 98% success rate in appropriately selected patients with primary hyperparathyroidism. This, however, is not 100%. Occasionally, parathyroid adenomas exist in what are called "ectopic" positions. Such parathyroid adenomas, because of their embryologic origins, can be in unusual places in the neck as well as in the area behind the sternum (mediastinum). Such parathyroid adenomas are unusual but occur in one to three percent of cases. In such circumstances, if the surgeon is unable to find the adenoma within the neck, he or she will most likely terminate the operation. Upon recovery, monitoring of the serum calcium levels will be done over the next several months. If the levels continue to be elevated, specialized tests including sestamibi scan, CT or MRI scanning may be performed in an attempt to find the adenoma. Continued elevated calcium levels may well require a second surgery.

Another recognized complication of parathyroid surgery is the possibility of recurrent laryngeal nerve damage. In experienced hands this should be much less than 1.0%; however the recurrent laryngeal nerves run immediately adjacent to the parathyroids and injury has been known to occur. If one or both nerves are damaged significant hoarseness can result. This is an especially important consideration in patients undergoing a second or reoperative neck exploration for parathyroid disease.

At the University of Virginia, Dr. Hanks' experience in parathyroid surgery includes 70-75 such operations per year.