How many parathyroid glands can be identified during thyroidectomy?

Abstract

SummaryBackgroundThe purpose of this study is to provide guidance for medical experts regarding malpractice claims on permanent hypoparathyroidism by analyzing the number of parathyroid glands (PGs) identified during thyroidectomy and the clinical outcome.MethodsParathyroid findings were documented in a standardized protocol for 357 patients undergoing thyroidectomy and treated by a single specialized surgeon. The resected thyroid was routinely dissected for accidentally removed PGs with consecutive autotransplantation and the pathological report also described unintentionally resected PGs. Follow-up was performed for 6 months.ResultsThe mean number of identified PGs was 2.28. No PGs were found in 20 (5.6%), one in 56 (15.7%), two in 126 (35.3%), three in 114 (31.9%), and four in 41 (11.5%) cases. One patient (0.28%) had manifest permanent hypoparathyroidism, while ten patients (2.8%) had latent permanent hypoparathyroidism (hypocalcemia and normoparathyroidism). The risk factors identified for postoperative hypoparathyroidism were an increasing number of visualized PGs, autotransplantation, central neck dissection, and PGs in the histopathological work-up. For permanent hypoparathyroidism, PGs in the histology examination and neck dissection were significant, but the number of identified PGs was not.ConclusionEven an experienced surgeon is not always able to find all four PGs during thyroidectomy and occasionally identifies none. Rather than focusing on identifying a minimum number of PGs, it is more important not to miss them in risky positions. A documented awareness of PGs, i. e., knowledge of variable parathyroid positions and their saving, is a prerequisite for surgical quality and to protect surgeons from claims.

Potential protection of indocyanine green on parathyroid gland function during near-infrared laparoscopic-assisted thyroidectomy: A case report and literature review

“…In our department, we usually perform limited lobectomy with isthmectomy + prophylactic CLND for patients with low-risk single small PTC. Hypoparathyroidism, an ongoing and frequently underestimated complication after thyroid operation, leads to hypocalcemia and serious medical problems[ 9 , 21 ]. Comparing hemithyroidectomy with all other surgical procedures, prolonged surgery (total thyroidectomy) and the diagnosis of malignancy are predictors of transient and permanent hypo-parathyroidism[ 22 ].…”

Moderne Schilddrüsenchirurgie – das endokrin-chirurgische Verständnis des Operateurs und seine Verantwortung für Resektionsausmaß und Komplikationsrate

“…Eine Anzahl dargestellter Nebenschilddrüsen, die zur sicheren Vermeidung des Hypoparathyreoidismus erforderlich ist, ist nicht definierbar, da die Position der Epithelkörperchen einer großen Variationsbreite unterliegt -oft auch in deutlicher Distanz zur Schilddrüse bzw. auch außerhalb der Schilddrüsenloge und somit nicht identifizierbar [10]. Dieser Tatsache sind sich Chirurgen immer wieder bewusst, wenn aufgrund eines primären Hyperparathyreoidismus ein zu entfernendes Nebenschilddrüsenadenom nicht an typischer Stelle liegt.…”

“…Die Lokalisation der Nebenschilddrüsen kann äußerst exponiert sein. Sowohl das Erkennen als auch das vaskularisierte Erhalten der Epithelkörperchen kann selbst für den routinierten Schilddrüsenchirurgen eine Herausforderung darstellen [10,11]. Die dritte eingriffstypische Komplikation, die Nachblutung, ist zu einem seltenen Ereignis geworden und wird deshalb im Zuge der modernen Aufklärung häufig vernachlässigt.…”

Video‐assisted parathyroid gland mapping with autofocusing

“…The PTGs are variably located on the back of the thyroid gland, buried in the central neck compartment tissues and not easily distinguished from other adipose or connective tissues by the naked eye. Therefore, it is often damaged during tissue dissection or found in extracted specimens unintentionally . If the PTG is compromised, it leads to complications, such as hypoparathyroidism.…”

“…Some studies have shown that inadvertent parathyroidectomy is approximately 18% during thyroid surgery, while patients experience temporary hypocalcemia (28.9%‐30.7%) and permanent hypocalcemia (1.6%‐9.6%) after thyroid surgery .…”