Historical Background

The purpose of surgical treatment in primary hyperparathyroidism (PHPT) is to remove enough abnormal parathyroid tissue to make and keep the patient normocalcemic. Patients with PHPT caused by a solitary parathyroid adenoma are almost always cured by removal of this adenoma. To accomplish unilateral neck exploration, the side on which the adenoma is located has to be known preoperatively, and this should be a true solitary adenoma rather than hyperplasia or multiple adenomas.

When Felix Mandl operated on his first patient for PHPT, the general belief was that enlarged parathyroid glands were the result of bone disease and deficiency of parathyroid activity; his patient, Albert, initially received a parathyroid homograft from a deceased patient. When the treatment failed to improve Albert's condition, Mandl had the knowledge, confidence, and courage to re-explore the patient and remove the pathologic parathyroid gland with at least temporary cure of the patient.1 In the early days of parathyroid surgery, removal of the enlarged gland was usually successful. However, with the recognition of primary parathyroid hyperplasia as a distinct histopathologic entity, it became obvious that more parathyroid tissue had to be removed.2 To be sure not to miss multiglandular disease, a bilateral neck exploration was advocated. Some surgeons even recommended incisional biopsy of the three normal-appearing parathyroid glands when a solitary parathyroid tumor was identified. Later, Paloyan and associates3 suggested that all patients with PHPT had hyperplasia and should, therefore, be treated by subtotal parathyroidectomy. During the 1970s, when the number of patients diagnosed with PHPT rapidly increased, it became obvious that bilateral neck exploration with biopsy of all glands had its price because some patients experienced postoperative hypocalcemia. In a Scandinavian survey, including more than 600 parathyroid operations performed during 1 year, hypocalcemia occurred postoperatively in about 15% of patients.4 Hypocalcemia occurred less often in patients undergoing only excision of the adenoma rather than biopsy and removal of more than one gland.4 A unilateral approach in patients with PHPT had been originally advocated in the 1970s by C. A. Wang.5 He used intraoperative oil red O staining and the saline float test to help determine whether a parathyroid gland was normal or abnormal. Unilateral parathyroidectomy was introduced in our department in 1977, and the initial 5-year results were presented in 1982.6

The principle for the unilateral approach is to restrict the neck exploration to the side on which the solitary adenoma is located. Originally, we did not use any localization studies; consequently, about half of our patients had unilateral approaches because 50% of the solitary adenomas were found on the left side and 50% on the right side. When a parathyroid adenoma was localized intraoperatively, the ipsilateral normal-appearing parathyroid and the adenoma were both removed, thus eliminating presumably all parathyroid tissue on this side. If the wrong side happened to be explored first, the two normal parathyroids were left intact and a contralateral exploration was performed. Again, both the adenoma and the normal parathyroid glands were removed on the second side. Intraoperative frozen section histopathologic examination was used to confirm the diagnosis of a solitary adenoma and a normal-sized parathyroid gland.

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