Difference between revisions of "Parathyroidectomy"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = Neuromonitoring ETT | ||
| lines_access = | | lines_access = PIV | ||
| monitors = | | monitors = Standard | ||
5-lead ECG | |||
Temperature | |||
Neuromonitoring | |||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = Relaxation with remifentanil if neuro monitoring | ||
| considerations_postoperative = | | considerations_postoperative = Hypocalcemia | ||
Recurrent laryngeal nerve palsy | |||
}}A '''parathyroidectomy''' is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies. | }}A '''parathyroidectomy''' is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies. | ||
| Line 23: | Line 27: | ||
|Hypertension and tachycardia are common | |Hypertension and tachycardia are common | ||
|- | |- | ||
| | |Pulmonary | ||
|Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) | |Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) | ||
|- | |- | ||
| Line 64: | Line 68: | ||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
* NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring | |||
* Preferably use video laryngoscope so surgery team can confirm lead placement | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
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*Supine | *Supine | ||
* Shoulder roll | * Shoulder roll | ||
*Reverse Trendelenburg or 30 degree HOB elevation | |||
*Head in Gel donut | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
* | *Avoid paralytic for nerve monitoring. Consider remifentanil instead. | ||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding | |||
** Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep. | |||
==Postoperative management== | ==Postoperative management== | ||
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|+ | |+ | ||
! | ! | ||
! | ! Open | ||
! | !Minimally invasive (endoscopic) | ||
!Minimally invasive (robotic) | |||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | |||
| | | | ||
| | | | ||
|- | |- | ||
|Position | |Position | ||
|Supine; shoulder roll; reverse Trendelenberg, headrest with gel donut | |||
| | | | ||
| | | | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
|1-2h | |||
| | | | ||
| | | | ||
|- | |- | ||
|EBL | |EBL | ||
|25-50mL | |||
| | | | ||
| | | | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
|PACU to either med surg for Ca monitoring x 24 hours, or PACU to home | |||
| | | | ||
| | | | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |3-4 | ||
| | |Less than open | ||
|less than open | |||
|- | |- | ||
|Potential complications | |Potential complications | ||
|Hypocalcemia: <15% | |||
Hypoparathyroidism: <5% | |||
Hematoma: 1% | |||
Infection: 1% | |||
Recurrent laryngeal paralysis: <1% | |||
| | | | ||
| | | | ||
Latest revision as of 16:37, 2 August 2025
Parathyroidectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Neuromonitoring ETT |
| Lines and access |
PIV |
| Monitors |
Standard 5-lead ECG Temperature Neuromonitoring |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Relaxation with remifentanil if neuro monitoring |
| Postoperative |
Hypocalcemia Recurrent laryngeal nerve palsy |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A parathyroidectomy is the removal of one or more of the parathyroid glands or ectopic glands in patients who have primary hyperparathyroidism. Patients typically present with elevated calcium and associated symptoms of hypercalcemia. For most patients with hyperparathyroidism, only one gland is affected (single adenoma), which allow for minimally invasive parathyroidectomy. However, most procedures are still open parathyroidectomies.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Hypercalcemia can cause altered mental status, weakness, myalgia, and rarely seizures |
| Cardiovascular | Hypertension and tachycardia are common |
| Pulmonary | Avoid respiratory acidosis, as this worsens hypercalcemia (less calcium bound to albumin) |
| Gastrointestinal | Hypercalcemia can cause constipation, nausea/vomiting |
| Hematologic | |
| Renal | Hypercalcemia can cause polyuria/polydipsia resulting in other electrolyte abnormalities. Also increased risk for nephrolithiasis |
| Endocrine | |
| Other |
Labs and studies
- EKG
- CBC
- BMP to evaluate calcium, magnesium, phosphate,
Operating room setup
Patient preparation and premedication
Patients should receive IV fluids and diuresis to control calcium levels.
Radioactive tracers such as methylene blue or technetium Sestamibi may be administered preoperatively to facilitate detection of parathyroid glands intraoperatively.
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
- Intraoperative nerve monitoring (IONM) is used by surgeon to avoid injury to recurrent laryngeal nerve
Induction and airway management
- NIMS endotracheal tube is used for recurrent laryngeal nerve monitoring
- Preferably use video laryngoscope so surgery team can confirm lead placement
Positioning
- Supine
- Shoulder roll
- Reverse Trendelenburg or 30 degree HOB elevation
- Head in Gel donut
Maintenance and surgical considerations
- Avoid paralytic for nerve monitoring. Consider remifentanil instead.
Emergence
- Ensure smooth emergence with minimal coughing/bucking, as this can cause neck bleeding
- Consider leaving remifentanil on (around 0.05 mcg/kg/min) or extubating deep.
Postoperative management
Disposition
Regular calcium levels to evaluate for postoperative hypocalcemia, which can occur in up to 15% of patients.
Pain management
Potential complications
- Symptomatic hypocalcemia
- Neck hematoma is rare but can develop rapidly, resulting airway compromise. Thus it is a surgical emergency requiring prompt takeback.
- Recurrent laryngeal nerve injury, if unilateral, results in a hoarse voice, but if bilateral, can result in obstructed airway requiring emergent tracheostomy
Procedure variants
| Open | Minimally invasive (endoscopic) | Minimally invasive (robotic) | |
|---|---|---|---|
| Unique considerations | |||
| Position | Supine; shoulder roll; reverse Trendelenberg, headrest with gel donut | ||
| Surgical time | 1-2h | ||
| EBL | 25-50mL | ||
| Postoperative disposition | PACU to either med surg for Ca monitoring x 24 hours, or PACU to home | ||
| Pain management | 3-4 | Less than open | less than open |
| Potential complications | Hypocalcemia: <15%
Hypoparathyroidism: <5% Hematoma: 1% Infection: 1% Recurrent laryngeal paralysis: <1% |
References
Top contributors: Tony Wang, Dominic Mangino and Chris Rishel