Surgical Approach to Primary Hyperparathyroidism Bilateral Approach

Quan-Yang Duh, MD

Surgery offers the only definitive treatment for patients with primary hyperparathyroidism.1 The success of parathyroidectomy depends on the skill and judgment of the surgeon. The best surgical approach should give the highest rate of cure with the lowest rate of complications. In this chapter, issues that influence surgical strategy are discussed. A strong case is made for surgeons to have a good understanding of the embryologic development of the parathyroid glands and to have experience in exploring thoroughly both sides of the neck during the initial operation for primary hyperparathyroidism. Advances in localization studies and intraoperative parathyroid hormone (PTH) monitoring allow the surgeon to limit the extent of exploration in some patients. Bilateral exploration of all four parathyroid glands, however, remains the "gold standard," against which the results of other approaches are evaluated. Bilateral exploration is necessary in patients who are at high risk for having multiple-gland disease, such as those with familial syndromes and those with negative localization studies. When in doubt, bilateral exploration, identifying all four parathyroid glands, is most likely to result in the highest success rate.

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