Parathyroid surgeryParathyroid surgery

George Ferzli MD, FACSGeorge Ferzli MD, FACS

SUNY Downstate SUNY Downstate Medical CenterMedical Center

Lutheran Lutheran Medical CenterMedical Center

• Total parathyroidectomies:Total parathyroidectomies: 132 patients132 patients

• Sex:Sex:– 32 males 32 males – 100 females100 females

• Age – 28 to 88 years (mean = 59)Age – 28 to 88 years (mean = 59)

Pre-op calcium = 9.1mg/dl - 13.8mg/dl (mean = 11.94mg/dl)Pre-op calcium = 9.1mg/dl - 13.8mg/dl (mean = 11.94mg/dl) Post-op calcium = 7.7mg/dl - 10.3mg/dl (mean = 9.50mg/dl)Post-op calcium = 7.7mg/dl - 10.3mg/dl (mean = 9.50mg/dl)

Pre-op PTH = 37ng/ml - 452ng/ml (mean = 124.6ng/ml)Pre-op PTH = 37ng/ml - 452ng/ml (mean = 124.6ng/ml)

Post-op PTH = 16ng/ml - 119ng/ml (mean = 53.2ng/ml)Post-op PTH = 16ng/ml - 119ng/ml (mean = 53.2ng/ml)

SESTAMIBI SCANSESTAMIBI SCAN

• Hyperfunctioning parathyroid gland: 114 patientsHyperfunctioning parathyroid gland: 114 patients• Inconclusive or no uptake: 14 patientsInconclusive or no uptake: 14 patients• Scan not done: 4 patientsScan not done: 4 patients

OR TIMEOR TIME

15’ – 165’ (mean = 42 minutes)15’ – 165’ (mean = 42 minutes)

ANESTHESIAANESTHESIAAll patients received general anesthesiaAll patients received general anesthesia• No intraoperative PTH assayNo intraoperative PTH assay• No image griddingNo image gridding

HOSPITAL STAY HOSPITAL STAY (mean = 1.1 day)(mean = 1.1 day)

129 patients129 patients == 1 day1 day

2 patients2 patients == 2 days2 days

9 patients9 patients == 9 days9 days

(psych patients)(psych patients)

LENGTH OF INCISION:LENGTH OF INCISION:2cm - 6cm (mean = 2.28cm)2cm - 6cm (mean = 2.28cm)

2cm -2cm - 93 patients93 patients

3cm -3cm - 37 patients37 patients

4cm -4cm - 1 patient1 patient

6cm -6cm - 1 patient1 patient

PARATHYROID GLANDPARATHYROID GLANDFrozen sections done for all patientsFrozen sections done for all patients

PATHOLOGIESPATHOLOGIESHyperplastic Hyperplastic 3535AdenomaAdenoma 9696CancerCancer 11

WEIGHTWEIGHT 70mg - 370mg (mean = 545.63mg) 70mg - 370mg (mean = 545.63mg)

SIZE OF GLAND SIZE OF GLAND 0.9x0.6x0.3 - 3.5x2.5x1 0.9x0.6x0.3 - 3.5x2.5x1

LOCATION OF THE GLAND LOCATION OF THE GLAND (dual adenomas in 2 patients)(dual adenomas in 2 patients)Right upperRight upper 99Right lowerRight lower 3737Left upperLeft upper 2828Left lowerLeft lower 5858

3 thyroidectomies done at the same time3 thyroidectomies done at the same time

COMPLICATIONSCOMPLICATIONS

• HypocalcemiaHypocalcemia 1 patient1 patient

• Vocal chord paralysisVocal chord paralysis 1 patient 1 patient (transient RLN)(transient RLN)

• False positive False positive SESTAMIBI scan: SESTAMIBI scan: 2 patients2 patients

LENGTH OF FOLLOWUPLENGTH OF FOLLOWUP

4 - 88 months (mean = 64 months)4 - 88 months (mean = 64 months)

January 2000 – April 2007January 2000 – April 2007

CONCLUSIONCONCLUSION

An incision is made along a An incision is made along a

skin crease high up in the neck.skin crease high up in the neck.

Superior and inferior Superior and inferior subplatysmal flaps are subplatysmal flaps are developed.developed.

Rt. recurrent laryngeal nerveRt. recurrent laryngeal nerve

Tubercle of ZuckerkandlTubercle of Zuckerkandl

Rt. upper parathyroid glandRt. upper parathyroid gland

At the laryngotracheal At the laryngotracheal junction, identify the junction, identify the following structures:following structures:

Middle thyroid veinMiddle thyroid vein

ligated and dividedligated and divided

The inferior pole vessels The inferior pole vessels are dividedare divided

If total thyroidectomy, repeat If total thyroidectomy, repeat steps on left sidesteps on left side

Free trachea from thyroid by Free trachea from thyroid by dividing ligament of Berrydividing ligament of Berry

Ligament of BerryLigament of Berry