Parathyroidectomy and Four-Gland Exploration for Hyperparathyroidism

CHAPTER 1

My name's Antonia Stephen. I'm an endocrine surgeon at the Massachusetts General Hospital. I perform thyroid and parathyroid surgery. Today we'll be talking about a parathyroid exploration or a parathyroid surgery. In this procedure, one of the most important determinants of how the parathyroid surgery is approached is based on whether or not the surgeon, myself, is planning to do a bilateral four-gland exploration of the parathyroid glands or a more focused or limited exploration of the parathyroid glands. What makes that decision is really based on several factors, probably most importantly, the preoperative imaging. Every patient that has parathyroid surgery undergoes preoperative localizing imaging to determine which one or ones of the four parathyroid glands are likely to be enlarged and abnormal, and which ones are likely going to need to be removed. In going into this surgery, this particular case was a planned four-gland exploration based on the patient's preoperative imaging, and also on her age and other factors. So the first step is to open the neck and expose the thyroid gland and the area around the thyroid gland, which includes the parathyroid glands. We make an incision in the anterior cervical portion of the neck, which usually measures approximately three to four centimeters. This is carried down through the platysma muscle, superior and inferior subplatysmal flaps are raised, and the strap muscles are divided in the midline of the neck. The strap muscles are then separated from the anterior surface of the thyroid gland, in this case, of a four-gland exploration on both sides of the neck. Step two of this procedure will be exposing and exploring, identifying all four parathyroid glands. Once again, we tend to start on the side that was indicated on the preoperative scans as being the most likely to be abnormal. In this particular case, that was on the left side. Both the left inferior and superior parathyroid glands are explored and exposed if possible. And then subsequently the right side parathyroid glands are explored. During this time, we determine which ones look most likely to be abnormal and plan to remove those. One of the most important parts of this procedure is making sure that some viable, healthy parathyroid tissue is preserved in order not to render the patient hypoparathyroid. Once this is done, it is then determined whether or not we are going to draw an intraoperative PTH level and await those results prior to terminating the procedure. After this has been done, the parathyroid tissue has been removed, it is confirmed on frozen section that it is indeed representative of parathyroid tissue, and we then either await the intraoperative PTH levels or decide to end the procedure. The neck is then closed in layers with 4-0 Vicryl. The strap muscles are closed in the midline. The platysma muscle is closed, and the skin is closed with a running 5-0 Monocryl subcuticular suture. We place Steri-Strips, and the patient is awakened.

CHAPTER 2

Every patient who undergoes a parathyroidectomy gets preoperative imaging for parathyroid localization. There are several options for that, and the ones that I typically get are a neck ultrasound and a four-dimensional CT scan, both of which this patient had. We typically make the incision somewhere between three and four centimeters. In this patient, we're planning a four-gland exploration based on her imaging. Jasmine, pull down right here with your right hand. Are you ready? Yeah. Okay. And are we okay to start? Good to start. Great. Take that hand and pull. 15 Bovie, please.

CHAPTER 3

Knife back. Pull hard. There you go. So the first layer that we'll go through, and in this older patient, it won't be terribly evident or well developed, is the platysma muscle. She's also quite thin, so it's important to be careful not to interfere with the anterior jugular veins as you go under the platysma. So now we're gonna raise superior and inferior subplatysmal flaps. By elevating the platysma with the forcep and carefully Bovieing just underneath the platysma to separate the attachments to the underlying strap muscles. Let's fix these lights. Watch your heads, guys. So one light needs to go directly from above and one directly from below. Much better. Okay, you can relax there, Jasmine. Thank you. We're now completing the, oops, inferior subplatysmal flap. And we'll take a small Weitlaner, please. And a DeBakey, please, and the Bovie to Jasmine. Yep, thank you very much. Okay. So Jasmine, you're gonna divide the strap muscles in the midline. So pick up on the, just to the left of there. Can I have the suction, please? And then right here, up and down. Be careful of those jugular veins. Good. And as we do this, we'll start to see the edge of what's called the sternohyoid muscle, which is the more superficial of the two midline strap muscles. Great. And you wanna pick up here. So Jasmine is now holding the left sternohyoid muscle, and she is separating the left and the right sternohyoid muscles in the midline. And she is going down towards the sternal notch. When you are planning to do a four-gland exploration, as we are in this case, it's important to get at least a decent amount of exposure room when separating the two strap muscles. If you're doing a focal exploration, this can be more limited. Right, that should be good. Okay, so we're gonna start at the left lower parathyroid, as indicated on the CT scan. Underneath the sternohyoid muscle is the sternothyroid muscle, which is right here. So hold that up right there, please, Jasmine. And when you're gonna separate the sternothyroid muscle from the underlying thyroid, stay right underneath the muscle, don't go down towards the thyroid. Good. And then you're gonna adjust your... Perfect. Good. Gimme a little buzz right here. So underneath the sternothyroid muscle is where we're gonna find the thyroid gland. And it's around the thyroid gland that we're gonna explore for the parathyroids. So we are carefully separating the sternothyroid muscle from the surface of the thyroid gland. And probably the most important part of this is to not Bovie into this thyroid gland itself because it will bleed and obscure your visualization of the surrounding parathyroid glands. So keeping this as dry and bloodless as possible is critical, because one of the things we rely on, you can let go there, in terms of identifying small, baby abdominal, as in terms of identifying the parathyroids is the color. And if the color gets stained with blood, it can be more difficult to see. So you're gonna gently hold that. Actually, Charles can do that.

CHAPTER 4

Can you tilt the table slightly towards me, please? And - stop. That's perfect. And hold that right there. And can you also drop the table a bit? I'll take a second forcep. That's good. Stop. So we are already seeing the left inferior parathyroid gland, even with that minimal exposure, because based on the CT, we knew exactly where to go. Here's the thyroid gland here, this sort of very vascular, almost kind of purplish, and right off the lower pole of the thyroid is a brownish structure that represents the inferior parathyroid gland on the left. Can I have a peanut, please? So we retract the thyroid up and towards me, up and medial to pull that parathyroid into our field. Could you turn the Bovie down to 15, please? Because we're gonna be very close to the recurrent laryngeal nerve, I'd like the Bovie on a very low setting so we don't cause thermal injury. So you're just gonna tap that little... Right here? Nope. That tissue right there. You don't need to hold it. Perfect. It was nice how you didn't hit the parathyroid there. And this parathyroid is very clearly abnormal. It's larger and darker than it should be. All right, Harmonic, please. Jasmine, do you know how to use the Harmonic? So, basically, you just take the tissue in question. May I have a right angle first? And the key is not to pull up on the tissue because then it will just rip. I'll do this one and show you, and then you can do the others. Maureen, is it possible for me to get a step, please? So now we're separating the attachments around the left inferior parathyroid. Can you turn the nerve monitor on, please? Yes. And make sure it's on two. Turn it up to four, please. Great. So that's the signal of the recurrent laryngeal nerve, which is behind the parathyroid gland. Here's the lower pole of the thyroid. Here is the left inferior parathyroid gland, a brownish structure that is just coming off the lower pole of the thyroid. As you can see here very nicely, the blood supply to the parathyroid is coming from the lower pole of the thyroid. Underneath here is the trachea, and the recurrent laryngeal nerve is a tad more lateral, as we just stimulated it in that area. Okay, Bovie to you, please. So you wanna get a forcep, and then actually if you can just gently retract on the blood supply. So we're coming up towards the thyroid here. Just tap very superficially there to free up some of the superficial attachments. Great. So we are gonna go ahead and remove this gland. Nope, gimme a little buzz, please. Good. So we're - underneath here is the trachea. Tip that towards me, please. Can I have a suction and then the right angle? Okay, pick that up in the air. Great. Right angle, please. We are now taking the blood supply... Can I have a small clip, please? To the parathyroid gland, which is coming from the lower pole of the thyroid. We're gonna place a small clip. And then second forcep to me, please Actually, gimme a little buzz right there, please. And then hold that gland up in the air, and you're gonna buzz that right there. Good, Jasmine. Good, right here. A little closer to the para. Hold on, hold on. A little farther away from the thyroid. Great. Hold on. It's important to separate... The more posterior attachments of the inferior parathyroid gland can actually be quite close to the recurrent laryngeal nerve. So lay that down right here. So this is the left inferior parathyroid gland. Forcep. I'm gonna point out a few things. The way we know that this gland is abnormal is number one, it's larger than it should be. It should be about that big, and it's about three times, if not more that size. Second of all, the color is darker than it should be. A normal parathyroid gland is a lot lighter in color, a lot more yellow and looks more like fat. And this is darker or browner. And the reason for that is that abnormal parathyroid glands, enlarged parathyroid glands, have less fat and more cells. The cells that they have more of produce PTH. And that's why in patients with primary hyperparathyroidism and an enlarged gland like this, the PTH is high. So the more cellularity, the darker in color. So, number one, size. Number two, color. Number three, contour. This is thicker and rounder than a normal parathyroid. A normal parathyroid would be much flatter. And then the fourth thing is the compressibility. So when I push on this, I can't flatten it out because it's more cellular and enlarged. So those are the four criteria we use to assess visually if a parathyroid is abnormal: size, color, shape, and compressibility. Can you call the frozen section? We get a frozen section to verify this is actually a parathyroid gland, but I don't have a lot of doubt in that regard here. Left inferior parathyroid for frozen. Peanut, please. Yep, for frozen section, please. So we've now successfully explored the left inferior parathyroid gland and removed it. We're now gonna go ahead and look at the other three glands, but we're not gonna remove any of them until we see what they look like. Come up above please, Charles. The superior parathyroid gland is more posterior in the neck than the inferior. So we're just clearing a space behind the thyroid now in a more posterior location. Peanut to me. Yep. And once again, a critical move is the upward and medial retraction of the thyroid gland. That's it, Charles. Thank you. Gimme a little buzz here please, Jasmine. And once again, we do have to separate some of... You're gonna buzz right on the tissue there, Jasmine. See right outside my forcep? Good. We have to separate the muscle away from the thyroid in order to access the area around the thyroid, which is where we're likely to find the parathyroid glands. So right now we're exploring the fat behind the mid and upper pole of the thyroid posterior to the recurrent laryngeal nerve, which was where we're likely to find the superior parathyroid glands. So the nerve runs up here, the inferior gland is anterior to the nerve in the neck, and the superior gland is posterior to the nerve. Can you turn the nerve monitor down to two, please? Forcep. Thank you. Do we have the short one? And a lot of the dissection we do in exploring these glands is blunt dissection. So oftentimes, when a gland is normal, especially in an older person, sometimes we don't distinctly see it, but we see an area in the fat that looks to be slightly darker, and that could be her normal parathyroid gland. So right behind the thyroid here is where we would anticipate finding the normal left superior parathyroid gland. And I suspect it's living right inside this fatty tissue here. Okay, we're now gonna explore the right side. So Jasmine, you're gonna gently hold the thyroid isthmus towards you, suction to me, and then right under this muscle here to start, and then we'll get under the sternothyroid after that. Older people, and this patient is 81, are more likely to have multigland disease, but the appearance of that first gland could have been consistent with a small adenoma, meaning she may not have additional abnormal glands. Kaylee? Yes? Can you just look up her most recent PTH for us? Right under my forcep there, just keep your retraction going. Good. Way up here. What was it? 24 on 11/18/2023. Great. Could we plan to draw one? Intra-op? Yes. Sure. In about 10 minutes from now. Sure. Could I have a piece of surgicel, please? Buzz me. Right here. It's ready. In an older person with fragile tissue, you can sometimes get a little bleeding from the thyroid gland, just from retracting it. So it's important to control that early on for the reasons we discussed earlier where you do not wanna stain the tissue around the thyroid, which can obscure and change the color of the parathyroid glands. And as we discussed, gimme a buzz there, the color is one of the criteria we use in determining if the parathyroid is abnormal. Way up there. Gimme a little buzz here, Jasmine. Thank you. And then way out by the, good. So Jasmine, my assistant here, is holding the right thyroid gland. Okay, could I have a baby abdominal? You're gonna let go. And we're gonna get a peanut, please. And Charles, if you could come over here. And you're gonna put that forcep down, please, Jasmine. And now, Jasmine, from her side, as I was doing on the other side, is gently holding the thyroid up and medial so that we can expose the area around the thyroid. Below you? Gimme a buzz, below me for now. Thanks. Thanks, Ella. Okay, right out there. Right here. Oh, thanks, Charles. Hold that right there. Give it a little tug. That's it. So you're gonna come right along my forcep here. So right now, we're separating the sternothyroid muscle from the thyroid gland. Once again, in order to expose the area around the thyroid, which is where we'll find the parathyroid glands. So I do see the right inferior parathyroid gland. Forcep to me. I'm gonna back this up. One of the important things in parathyroid explorations is when you're holding the thyroid with the peanut or whatever you're using to hold the thyroid up, that you don't place it where the parathyroid could be. Does that make sense, Jasmine? So you can actually pull the parathyroid up and then not see it, 'cause it's like under your forcep. Yep. So she is, Jasmine is doing a great job holding the thyroid up, and actually displaying beautifully the right inferior parathyroid gland, which is located right here. It's very fatty, it's stuck to the lower pole of the thyroid. And we're gonna expose it a little bit more, but I believe it looks most likely to be normal. It's much lighter in color. Do you see that right there? And we may choose to expose this further. Buzz? You're just gonna buzz the tissue right there. So we're now, once again, just doing a very detailed and complete exploration of the right inferior parathyroid gland, which in this particular patient is attached to the right lower pole of the thyroid. So here is the parathyroid. Do you see that there, Charles, too? Yes. See it right here? Now what I'm not sure of, I think here, see this right here? That is fat. See how it's yellow? Yep. Do you see that, Jasmine? Yeah. This is the parathyroid. Yep. And it gets a little darker when you expose it because we make it ischemic. So, sometimes you can get fooled that it could be abnormal. I think this one is normal. We may expose it more after we look at the superior on the right. So you're gonna come above me, please, Charles. Jasmine is gonna continue to do this great job holding the thyroid up. And once again, we're back to separating the sternothyroid muscle from the thyroid so that we can see around the thyroid. And for the superior gland, as on the left, we need to go very posterior. Probably the most critical thing in exposing the superior parathyroid glands is the medial and upward retraction of the thyroid. Buzz me. Stay way out on the muscle there, please, Jasmine. Way out towards my forcep. Good. Gimme a little buzz. Another buzz. So we're now seeing the carotid artery out here laterally. And one of my dictums is that if you can see the carotid artery, you cannot see the superior parathyroid gland. Because if you can see the carotid artery, you're too superficial and you're too lateral. So I'm gonna get a deeper retractor to retract the carotid artery so we can get medial and deep enough. So Charles, you're gonna gently hold the carotid over. And now just as we were doing on the left, we're looking very posterior here for the superior parathyroid gland. Once again, remembering that it could be quite fatty and posterior. And I think we see it actually right here. There it is. Push that down. Pull that up. So that is the right superior parathyroid gland. And I do think that this one also looks abnormal. It looks hyperplastic. So that means we're gonna go back and investigate further the left superior gland. Okay, so relax. Marking pen, please. So at this point in the case when we're gonna decide what we're gonna remove and what we're gonna leave behind, 'cause you can't remove all the parathyroid glands, I like to draw a picture of what we've seen thus far. So here's the trachea, here's the thyroid. This one was clearly enlarged, the left inferior. And it's been removed. This one we have not definitely seen, right, guys? This one we saw here, and it actually looks quite normal, the right inferior. This one we saw here, and it looks slightly smaller but similar to the left inferior. So at this point, we're certainly planning to remove this one. We may be leaving this one in place, and we need to further explore the left superior gland. So I'm gonna come over there to take a look at that. And then, Hailey, let's hold off on that level. I'm gonna have you do it probably later 'cause we found another abnormal gland. So once again, the most critical step in exposing the superior parathyroid gland, lemme try the baby abdominal, is making sure that you have upward and medial retraction of the thyroid to expose the area where you'll find it. Don't pull too hard there, Charles. Let her pull medial. And you're gonna take this peanut, please, Jasmine. So the right superior parathyroid gland we found right back here. That all looks like fat, not parathyroid. And you should be able to palpate, with either your finger or your forcep, the spine. That means you're behind the carotid, and you're deep enough to expose the superior parathyroid gland. The superior parathyroid gland shares a very close relationship with the recurrent laryngeal nerve. So that's another thing to look out for during this exploration. Okay, so there we go. The recurrent laryngeal nerve, which we have not fully exposed, is running in the TE groove. Crossing over it right here is the inferior thyroid artery. Usually just posterior to that junction is where you're most likely to find the superior parathyroid gland. Gimme a tiny buzz here, please. Good. It's not unusual when you're dealing with smaller glands, even when they're enlarged, to sometimes have to do some extra exploration to find one or more than one of them. In this case, the one that we're missing is the left superior, and there is the recurrent laryngeal nerve. Do you see it in there, Charles, too? Jasmine sees it. See, it's the white one right here. Crossing right under the inferior thyroid artery. So seeing that is really helpful because I know the para is behind the nerve, so there's absolutely no reason for me to be looking anywhere here, 'cause that's where the inferior gland is located, and we've already removed that. So, great. Hi. I have the frozen section results for you. Thank you. That's good. This is left inferior, the first gland. It is abnormally cellular. It's a little bit nodular. Are you suspecting abnormal or hyperplasia? Hyperplasia. Yeah, okay. Yep. It makes sense. Thank you so much. We may have one or two more. Okay. This is the esophagus back here. So now we're gonna look behind the upper pole of the thyroid 'cause we're actually not able to usually visualize the left superior. That's one of the first places I look, and I don't see it up there. We do have good exposure, thanks to Jasmine and Charles. And then the next place I'm gonna look is down along the TE groove. Once again, staying behind or posterior to the recurrent laryngeal nerve. Recurrent laryngeal nerve is right here. And we now have good exposure of the inferior thyroid artery as well. More exposure of the esophagus, right there. So when I'm unable to see one of the glands, it's possible it could be quite normal and fatty. It's also possible it could be sitting more medial inside the thyroid gland. There are other ectopic locations that we think about. But then the question comes up about whether or not we actually do need to visualize it. And oftentimes, we don't, in particular if we can check the intraoperative PTH after removal of the visualized glands that are enlarged. So, we're just gonna check right here along the thyroid now. So that to me looks more consistent with thyroid tissue. Do you see that right there? Yeah. Esophagus. This is where one would expect to see the superior parathyroid gland. Behind the upper pole, along the TE groove. There's an entity that we call a descended superior gland, where it is lower down in the neck towards the clavicle but still very posterior. So we're exploring that region as well. We are not exploring anywhere anterior to the nerve. And the reason for that is we've already removed the left inferior parathyroid. So here, Jasmine, along the posterior peduncle, occasionally you can find the superior parathyroid. So one should always carefully inspect the tissue around the peduncle. So I don't see clearly the left superior parathyroid gland despite a detailed exploration. So we're gonna switch sides again and return to the right. First, we're gonna return to the right inferior parathyroid gland. Chuma, you're gonna hold this, I'm sorry, Charles, you're gonna hold this right here. And a peanut, please, to Jasmine. So we're gonna do a little bit more of a detailed exposure of the inferior gland. Which looks quite normal. So I was considering whether or not we wanted to biopsy it, and I would say no. So the things that I'm most interested in here is number one, size. It's normal in size. It's about three millimeters here, right? Second, color. Is it more yellow, sort of peanut butterish, or is it darker? It's more yellow peanut butterish here. It's actually quite pale. Number three is the shape. It's round here, but is it flat? If it's flat, it's more consistent with the normal. And I believe the tissue behind it here is thyroid tissue, that it's a flat, sort of plastered up. Does that make sense? I think that's thyroid tissue right there. Yeah. And number four is, see how compressible it is? Yeah. So I suspect that one is a normal parathyroid. We're now gonna return to the right superior, which Jasmine is beautifully displaying right there. You're gonna hold that there, but don't pull too hard, Charles, okay? So this one is very clearly abnormal. It's larger. Ruler? We called the other one about three millimeters that we said was normal. This is about eight millimeters. It's darker, right? Significantly darker than the fat, and significantly darker than the lower parathyroid, right? Which is right here. See the difference? This is actually a beautiful illustration of a normal versus an abnormal or a hyperplastic parathyroid gland. Right inferior is normal, right superior is hyperplastic or overgrown. It does not however appear to be an adenoma. So this one here is larger, darker, rounder in the back, and less compressible. However, it is not as incompressible as an adenoma would be. Adenomas are often even larger than this, darker, almost purple in color, rounder in shape, more like a tumor, and less compressible even than this hyperplastic gland. So we're carefully separating... Can I have a small clip, please? And a pair of scissors, please, to Jasmine. So we're clipping the blood supply, and then cut right near the parathyroid, not near the clip. Great. Perfect. So that one, actually, I would say is smaller and more compressible than the left inferior that we removed. The left inferior was more consistent possibly with a small adenoma. This one looks hyperplastic. Okay, now in 10 minutes. 10 minutes. Yep, we can draw the PTH. What are you labeling that one? That's gonna be the right superior parathyroid gland. So I just wanna make sure that our clip here is secure on the blood supply. Can I have a second small clip, please? Right superior parathyroid gland? Yep. For frozen? Correct. I'm just securing the blood supply of the parathyroid coming from the midpoint of the thyroid gland. So that is the stimulation of the right recurrent laryngeal nerve. So we have a good signal from the left and from the right. So, relax, everybody. Marking pen. So here's where we are at this point. We've now - we removed the left inferior, it was confirmed as an enlarged parathyroid gland on frozen section. We've removed the right superior, and we're sending that for frozen section. We've confirmed this as likely a normal parathyroid, right inferior. And we still haven't definitely identified the left inferior. Now I think back to my scan. And what was seen on the scan, this one, and then a question mark here, but none here. So what we're gonna do now is we're gonna check to see if the parathyroid level, the PTH, drops from removal of the left inferior and the right superior. Okay, any questions? So now I'm gonna check for hemostasis, because if the PTH comes back low enough... Can I have a retractor? This right here. We are gonna be done with this operation. Irrigation, please. Ready. Hmm. Now I'm wondering if that's a little... It's mostly fat. Let's just separate that a little bit there. So a little tap right there without getting into the thyroid. Mm-hmm. See what I'm saying? Like what if all of that is part of it? Yeah, no part of it can be that when you explore it, you make it a little bit ischemic. Right, like it looks different now than what it did... Yeah, it certainly, Right, I know. Like 10 minutes ago. But what we can do, so we're back on the right inferior gland, kind of inspecting it and trying to decide if it's mildly hyperplastic. We know we still have in place a left superior. Correct? But we don't wanna remove this whole thing 'cause we think it's likely normal based on our assessment earlier. Give me a little little buzz there. So what we're gonna do is we're gonna do a small biopsy. Can I have a medium clip? And so your last frozen for now is going to be... You're gonna get a knife. Mm-hmm. Biopsy of right... Size of the clip? 15. Of right inferior parathyroid gland. Inferior parathyroid gland? Yeah, biopsy of, right on the - the clip applier there. Knife back. Here's the biopsy. Very tiny. Mm-hmm. Thank you. So we'll sort of take a look here. That looks good. Okay, can I have some Surgicel, please?

CHAPTER 5

Thank you very much. Mm-hmm. Thank you for having that ready to go. You can leave it right up here. Okay, relax with the peanut. Now we're gonna check the other side. No, we're good. We're just gonna tuck into... A little irrigation, please. And a forcep, please. Pull with the retractor, please, there, Jasmine. May I have the suction, please. Oh, you got it. Suction? Yep. I need that. Yeah, we need the Surgicel. That's there. Okay, 4-0 Vicryls, please. So we're gonna close up and wait for the PTH. Here you go. Thank you. Yep.

CHAPTER 6

So I just close the sternohyoid muscle with very small... You can go this way, yep. Right there, small bites. So it's really important just to take very tiny bites of the strap muscles when you close them. Once again, I only close the sternohyoid. Can I have a another forcep, please? DeBakey. Great. Just be careful pulling, it doesn't pull through the muscle. And you wanna leave just a couple millimeters. Okay. Once again, be careful pulling up on that suture 'cause that muscle's fragile. So what I was explaining to Jasmine is it's important not to get bigger bites of the strap muscles, especially in a thin person like her, 'cause it can create a catching feeling when they swallow. I think we wanted a little shorter tail. Yeah, I'll just, yep. That's okay. That's all right. Yep, you can leave a little more space. When you're taking tiny little bites like this like we like, Jasmine, sometimes it's helpful to catch a tad bit of fascia, you know what I mean? I think you're gonna be fine here. But you know what I'm saying? So that way it won't rip, yep. But go ahead and tie that. Kaylee, do you have a timer on the PTH level? I do. Great. So getting back to our drawing... Marking pen. The only additional part of this that we've done is we did a small biopsy of the left inferior. Good. And see how nicely she's avoiding the anterior jugular vein, which is just lateral to where she's sewing. Adsons, please. And you can come down below me here, Charles. You can keep your scissors. Adsons and a Vicryl to us, please. Or a Vicryl to Jasmine. Let's switch out my Vicryl for a longer one. Adson. Another Adson. Yeah, she needs a stitch. Yeah, we're gonna need a full length after this, though. So this is just a platysma, buried platysma stitches. Good. And the key with this stitch, Jasmine, is to make sure you don't hook any dermis, 'cause you don't wanna tack the dermis to the muscle as you're closing. Once again, small. So see how I, there's no dimple here. Yeah. That's good. Yep. And if you hold that up, if you could cut way up here, please, Charles, if you can cut. Pass the needle back. There's a needle coming back, please. Needle back. It's not protected. This would be easier if we had unextended her neck, but I'm not doing that 'cause we haven't gotten the PTH back. We don't know yet. Exactly. And that can be cut short please, Charles. Perfect. Great. I'll take another, thank you. Just make sure you don't get any dermis. Mm-hmm. Right here. Good, Jasmine. And then you're gonna put one on the other side. The count is correct. Thank you. So because we didn't get good visualization of the left superior, we are gonna wait for the intraoperative PTH levels. Has that been, oh, that's being drawn right now. Is that Maureen over there? Yes. Could you please call the lab, make sure you get a live human being, and make sure they know that we're sending a stat intraoperative PTH. And have them confirm that they've received it with us, please. So I would say probably something platysma-ish in the corner here, and then a running Monocryl, 5-0. Okay, thanks, guys.

CHAPTER 7

What we found in this particular patient, this is an elderly patient, an 81-year-old female with hyperparathyroidism, the first step is to determine her indications for surgery, which in her was osteoporosis and a history of kidney stones. Her preoperative imaging suggested that she had multigland parathyroid enlargement, and we therefore planned a four-gland exploration. The preoperative imaging that we obtained for this patient included a neck ultrasound and a four-dimensional CT scan. We noted in this patient that the largest gland on the CT, the left inferior gland, was indeed very clearly enlarged, and actually appeared to be a small adenoma. We removed this gland as it was the first one we had explored, and we identified it as clearly abnormal. At this point, we explored the other three glands: the left superior gland, the right inferior gland, and the right superior gland. At this point, it's very important not to remove any additional parathyroid tissue until the remaining three glands are identified and it is decided which of those glands or which part of one of those glands will be preserved. The left superior gland, despite a fairly extensive exploration, was not definitively identified in this patient. The right inferior gland was identified as a likely normal parathyroid gland. The right superior gland was identified as hyperplastic or abnormally enlarged. The right superior parathyroid gland was removed. The right inferior parathyroid gland was biopsied with a small viable remnant left in place. And after a second re-exploration of the left superior location, we did not definitively identify the left superior parathyroid and presumed it likely to be normal. Because we had not identified the left superior gland and there was still a chance that it was hyperplastic or abnormal and contributing to the patient's hyperparathyroidism, we decided at this point to await the intraoperative PTH levels. This was drawn, and we noted that it dropped from a level of 80 preoperatively to a level of 28, approximately 10 minutes after we had removed the parathyroid glands. I personally prefer to see the parathyroid level drop to below 40. So as this was an adequate, we decided that at that point to end the procedure. So in this case, we had difficulty identifying the left superior parathyroid gland. The initial maneuvers to identify a superior parathyroid gland include mobilization of the thyroid gland medially and superiorly, and retracting it upwards and medially in order to identify and explore the area behind the upper and mid pole of the thyroid gland. That exploration usually reveals the left superior parathyroid gland. And in this case, it did not. It did, however, reveal the parathyroid gland on the right side. We returned to the left side to do a more detailed and extensive exploration of the left superior parathyroid gland. And the maneuvers we employed were, number one, we explored behind the upper pole of the thyroid gland on the left, which did necessitate additional exposure and additional removal of the sternothyroid muscle away from the thyroid gland. When we did not identify a parathyroid gland behind the upper pole of the left thyroid gland, we then exposed the recurrent laryngeal nerve on the left side and the inferior thyroid artery on the left side. This is an area where we do often identify the left superior parathyroid gland. The left recurrent laryngeal nerve was then traced down towards the clavicle, and we did a complete exploration of the left tracheoesophageal groove, which is once again an area where the left-sided superior parathyroid gland may have been identified. The final location that we explored was very medial where the nerve inserted into the larynx behind the thyroid peduncle. We were careful to inspect the entire thyroid peduncle to make sure there was not a small and normal parathyroid gland attached or underneath the thyroid peduncle. Those were the most important maneuvers that we employed in attempting to identify what was a difficult to find left superior parathyroid gland.