Although the parathyroid glands have a similar name and and often attached to the thyroid they are unrelated to and have a very different function to the thyroid gland. There are usually 4 parathyroid glands normally each only a few millimetres in size. However with parathyroid disease a parathyroid gland can increase to several centimetres in size. The parathyroid glands are essential for maintaining calcium levels at optimal concentrations in blood and body fluids.
What disorders can occur?
The parathyroid glands regulate calcium levels by secreting parathyroid hormone. This hormone acts to maintain serum and body fluid calcium concentrations by regulating gut absortion, kidney retention and reabsorption of calcium from the bones. Excessive production of parathyroid hormone is known as hyperparathyroidism and will result in abnormally high calcium levels. Persistently high calcium levels may result in the development of kidney stones, bony and muscular aches, osteoporosis, fatigue, abdominal discomfort and gastrointestinal tract disturbance. Suppressed or absent parathyroid hormone production is rare but will result in in abnormally low calcium levels. This condition is occasionally seen after thyroid surgery if injury or inadvertent removal of the parathyroid glands has occurred.
Why do I need parathyroid Surgery?
It is essential that parathyroid surgery is performed by an experienced parathyroid surgeon as the greatest chance of cure is at initial operation. As a specialist in the area of parathyroid surgery I welcome referrals for a second opinion or to reoperate when a previous parathyroid operation has failed by another surgeon.
The most common reason for parathyroid surgery is due to excess parathyroid hormone production resulting in abnormally high calcium levels. The diagnosis is usually confirmed by a blood test and measure of calcium excretion in the urine. The excess parathyroid hormone is most commonly due to the growth of a tumour in one of the parathyroid glands. The majority of these are benign (known as parathyroid adenoma) however approximately 1% of these tumours will be malignant (parathyroid carcinoma). In approximately 10% of patients all of the parathyroid glands may be enlarged and producing excessive parathyroid hormone. The most usual cause for this is due to renal failure or a due to a hereditary condition.
For a solitary parathyroid tumour only the involved parathyroid gland needs to be removed. If all four of the glands are enlarged typically 3 ½ of the glands are removed to treat the excessive parathyroid hormone but leaving enough of one gland to maintain some parathyroid function.
What incision will I have?
When the location of a parathyroid tumour can be confirmed by radiological imaging I will perform a minimally invasive parathyroidectomy which is typically performed through an approximately 2cm incision (depending on the size of the tumour). The incision will be made over the site of the tumour to allow direct access and minimal tissue injury. If the location of the tumour is uncertain I will perform a midline incision over the lower part of the neck utilising a natural skin crease where possible. This allows access and visualisation to parathyroid glands on both sides of the neck and can usually be performed through a 3-4cm incision.
For wound closure I use dissolving sutures and almost never require wound drains. This optimizes the cosmetic result and minimizes the discomfort a patient may experience with surgical drains or skin staples.
What will the scar look like?
In the early phase of healing the scar may be raised and red but in most cases the scar will fade to a faint white line and the majority become barely visible once full scar maturation has occurred (approximately 3 months). The size of the scar can be as small as 2cm for minimal access parathyroidectomy cases. Where a 4 gland parathyroid exploration is required the incision size is typically around 4cm in size. Patients with darker skin may initially have exaggerated pigmentation of the scar but this will also fade with time. Very rarely some patients develop a thick exaggerated scar (hypertrophy or keloid scar) but this is uncommon.
What complications can occur?
Most parathyroid operations are straightforward and associated with few problems. However all operations carry risks which include the potential for postoperative infection, bleeding into the wound and miscellaneous problems due to anaesthesia. Specific complications related to parathyroid surgery are rare but include injury to the laryngeal nerves (which may result in a hoarse voice) and hypocalcaemia (low calcium levels) due to suppressed function of the remaining parathyroid glands. As an expert thyroid and parathyroid surgeon my overall long term complication rate for thyroid and parathyroid surgery is less than 1%.
Will I need to be on Medications after my parathyroid surgery?
In most cases no specific medications are required after parathyroid surgery. Although the remaining parathyroid glands may initially be suppressed they rapidly “wake up” and begin functioning again after an overactive parathyroid gland or glands have been removed. In patients who have had more severe disease I may recommend a short course of supplementary calcium +/- vitamin D to avoid a temporary drop of calcium which can result from the suppressed parathyroid glands or from “hungry bones” which reabsorb calcium once the excess parathyroid hormone levels has been successfully treated by excision of the parathyroid tumours.
The exception to the above are patients with 4 gland disease (such as renal failure patients) even if a small portion of one of the parathyroid glands has been preserved. Most of these patients are already taking calcium +/- vitamin D to prevent the condition or recurrence of the condition after surgical treatment.
How long will I be in hospital and expected recovery time?
Almost all of my parathyroid patients who undergo minimally invasive parathyroid surgery are able to be discharged the same day of their procedure and usually able to return to driving and normal work the following day after surgery.
For my patients who require a 4 gland parathyroid exploration I usually recommend an overnight hospital stay although some patients are comfortable enough to go home the same day as their procedure. For these patients I usually recommend one week of recovery prior to returning to driving so that any early post-operative discomfort or neck stiffness does not impair driving ability. After a 4 parathyroid gland exploration most patients are able to return to work within 1-2 weeks after surgery for sedentary or light duty occupations and within 4-6 weeks for work requiring heavy manual labour.