Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
This 
chapter 
focuses 
on 
subtotal 
parathyroidectomy for hyperparathyroidism. Nearly 
15-20% 
of 
patients 
with 
primary 
hyperparathyroidism will present with 4-gland 
hyperplasia and require subtotal parathyroidectomy 
if indications for surgery have been met. Most 
patients with primary hyperparathyroidism are 
asymptomatic or with minimal symptoms. These 
patients present with hypercalcemia detected on 
routine blood work and inappropriately elevated 
parathyroid hormone level during further work up. 
Secondary causes of hypercalcemia must be 
excluded. The parathyroid diseases are described 
further in Approach to Parathyroid Disease.  
Neck 
exploration 
and 
subtotal 
parathyroidectomy are performed in the following 
steps:  
• Skin, platysma, and strap muscle incision 
• Medial rotation of the thyroid glands 
• Exploration and location of the recurrent 
laryngeal nerve and the parathyroid glands 
• Removal 
of 
the 
appropriate 
amount 
of 
parathyroid tissue 
• Hemostasis and closure 
 
Steps: 
1. In planning a bilateral neck exploration and 
subtotal parathyroidectomy, a slightly longer 
transverse incision (about 4cm) may be planned 
to optimize exposure. A longer incision is 
especially helpful in the re-operative setting, 
difficult 
anatomy, 
presence 
of 
a 
large 
multinodular goiter, or deep short neck.  
 
Neck incision, as seen on postoperative day 4. 
 
2. Generous superior and inferior subplatysmal 
flaps are developed to aid in adequate exposure. 
The strap muscles are separated at their midline 
and the plane between them and the thyroid gland 
is developed. 
 
The plane deep to the superficial layer of the deep cervical 
fascia is dissected caudally and cranially (shown) to the level 
of the suprasternal notch and the cricoid cartilage. Extend the 
dissection for several cm laterally in both directions as well. 
Source: Eugenio Panieri and Johan Fagen- 
https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-
48e5-81be-586fbaeba29d/Thyroidectomy.pdf 
 
3. When mobilizing thyroid lobes medially to 
visualize underlying parathyroid glands, dividing 
the middle thyroid vein will significantly 
improve both the easier visualization and 
exploration of the neck for the eutopic and 
Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
ectopic parathyroid glands. In rare instances, 
parathyroid glands are well visualized and easily 
accessible without dividing the middle thyroid 
vein. 
 
 
The middle thyroid vein will be the first large vein you 
encounter when dissecting along the anterior surface of the 
thyroid gland. Once it is divided, it is possible to rotate the 
thyroid gland medially even as you preserve its blood supply 
via the inferior and superior thyroid vessels.  
 
4. Dissect the capsule of the thyroid gland and 
rotate it medially to locate the superior and 
inferior parathyroid glands in their typical 
location 
posterior 
to 
the 
thyroid 
gland. 
Identification of the recurrent laryngeal nerve is 
a critical step in parathyroidectomy. Superior 
glands tend to lie posterior, superior and lateral 
to the nerve, while the inferior parathyroid glands 
are anterior, inferior and medial to the recurrent 
laryngeal nerve. 
 
The location of the parathyroid glands relative to landmarks 
seen during neck exploration. The horizontal line goes through 
the tubercle of Zuckerkandl, the most posterolateral part of the 
thyroid gland. The vertical line is an imaginary line drawn 
along the course of recurrent laryngeal nerve. Note that the 
superior parathyroid glands can be cranial to the entrance of 
the nerve into the larynx, even though this anatomic relation is 
preserved: Source: http://www.endocrinesurgery.net.au, used 
with permission. 
 
 
In this patient with secondary hyperparathyroidism, all four 
parathyroid glands can be seen after medial mobilization of the 
right (Left photo) and left (Right photo) thyroid lobes. They are 
in their normal location, shown by the White arrows. Source: 
Min Song Kim et al. 
https://doi.org/10.21053%2Fceo.2019.01340  
 
5. If operating for primary hyperparathyroidism, 
remove 
the 
gland(s) 
which 
are 
clearly 
hypertrophied. As explained previously, if you 
do not have intraoperative parathyroid hormone 
assay analysis, you must inspect all 4 glands, as 
Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
more than one will be hypertrophic in 15-20% of 
cases. 
6. If 
operating 
for 
secondary 
or 
tertiary 
hyperparathyroidism, decide whether to perform 
3.5-gland resection or 3-gland resection. This 
decision depends entirely on the size, position, 
and blood supply of the remaining parathyroid 
gland. Typically, the smallest and most normal 
appearing of the parathyroid glands is selected 
for subtotal resection and is marked either with a 
clip or non-absorbable colored suture for future 
identification. If the blood supply or very small 
size of the normal parathyroid gland do not allow 
subtotal resection without compromising its 
viability, then leaving a marking stitch or metal 
clip will suffice. 
 
Completed subtotal parathyroidectomy: based on the anatomy, 
the surgeon decided to do a subtotal resection of the left inferior 
gland. 
Source: 
Min 
Song 
Kim 
et 
al. 
https://doi.org/10.21053%2Fceo.2019.01340  
 
Three procedures are commonly performed 
for secondary and tertiary hyperparathyroidism:  
● Total parathyroidectomy with or without 
autotransplantation,   
● Subtotal parathyroidectomy 
● Limited parathyroidectomy- in case of 
tertiary hyperparathyroidism.  
The decision to select one of the above-
mentioned procedures lies with treating surgeon 
preference, available institutional resources and 
should be tailored to each patient’s treatment 
plan, including access to high-calcium bath 
dialysis, oral calcium pills, vitamin D and access 
to calcimimetics in cases of postprocedural 
hypoparathyroidism 
or 
failure 
to 
cure, 
respectively. 
7. Be very careful to assure hemostasis before 
closure. 
Patients 
with 
secondary 
hyperparathyroidism on dialysis are especially 
prone to postoperative neck hematoma.  
8. Reapproximate the strap muscles and the 
platysma and close the skin.  
 
Pitfalls 
● Intraoperative hemorrhage- blood staining of the 
tissues makes it much harder to distinguish 
between parathyroid tissue and normal fat. Be 
meticulous. Bipolar diathermy is especially 
useful for bleeding that is near the recurrent 
laryngeal nerve.  
● Recurrent laryngeal nerve injury- this is less 
common than during thyroidectomy, but still a 
risk. The nerve must be visualized and its relation 
to any parathyroid tissue assessed. At times it can 
be quite close to the tissue you want to resect.  
 
Photograph showing the relationship between the recurrent 
laryngeal nerve and the inferior thyroid artery (artery retracted 
by a Black suture). The artery may have a single or multiple 
branches, which may pass anterior or posterior to the nerve, or 
both. As the inferior thyroid artery is the blood supply of both 
the superior and inferior parathyroid glands, this relationship 
is 
especially 
important. 
Source: 
Chintamani 
https://doi.org/10.1007/s12262-017-1691-2  
 
Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A parathyroid adenoma that is dangerously close to the 
recurrent laryngeal nerve (Blue arrow.) Careless technique or 
less than meticulous dissection would lead to nerve injury and 
hoarseness of voice. 
Source: 
http://www.endocrinesurgery.net.au, 
used 
with 
permission. 
 
● Concurrent thyroid and parathyroid pathology: 
If the patient has a multinodular goiter, 
parathyroid identification can be even more 
difficult. Thyroid gland mobilization and/or 
concurrent thyroidectomy may have to be 
planned, if indicated. Preoperative ultrasound 
examination by the surgeon can help prepare for 
this situation. If feasible, a partial thyroid 
lobectomy can be performed in place of a total 
lobectomy to incorporate an area containing a 
nodule suspicious for an ectopic parathyroid 
gland and submitted to pathology for further 
analysis.  
● Failure to localize all four glands: Embryology of 
parathyroid glands dictates ectopy and difficulty 
in 
intraoperative 
localization 
of 
ectopic 
parathyroid glands. Ectopic positions can range 
from high cervical position, inside carotid sheath, 
intrathyroidal, within the tracheoesophageal 
groove, 
retroesophageal, 
mediastinal 
or 
intrathymic. Identifying the parathyroid vascular 
stalk and where parathyroid blood supply is 
coming from in relation to the recurrent laryngeal 
nerve can be very helpful in identifying which 
gland, superior or inferior, is being resected. 
 
Embryology of the pharynx, 6th to 7th week of development. 
The inferior parathyroids originate in the third branchial pouch 
and the superior parathyroids originate in the fourth branchial 
pouch. Both migrate downwards into the neck: as the inferior 
parathyroids have farther to travel, they are more prone to 
migrate to an ectopic location. Source: 
http://www.endocrinesurgery.net.au, used with permission.  
 
● For a missing superior gland, inspect:  
● The tracheoesophageal groove both 
above and below the thyroid gland,  
● Inside carotid sheath,  
● Inside the thyroid capsule (subcapsular 
gland), 
● Above the superior pole of the thyroid 
lobe- examine for a high cervical ectopic 
gland, or perform thyroid lobectomy. If 
the inferior parathyroid gland has already 
been 
identified, 
a 
transcervical 
thymectomy can be performed as well.  
● For a missing inferior gland, inspect: 
● Thyrothymic ligament and cervical horn 
of the thymus, the most common ectopic 
location for inferior gland, 
● Inside the carotid sheath, 
● Below the inferior pole after taking down 
inferior pole vessels,  
Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Inside the thyroid capsule (subcapsular 
gland), 
● 
 Inferior tracheoesophageal groove, 
● As many of the following positions as 
you can access: 
 
Potential ectopic parathyroid locations, for both superior and 
inferior glands. Source: http://www.endocrinesurgery.net.au, 
used with permission. 
 
● If all of these measures fail, perform 
transcervical thymectomy first and bisect 
the thymus to confirm the presence of 
parathyroid tissue. If the gland is not 
apparent in these tissues, then perform 
thyroid lobectomy ipsilateral to the 
missing gland. 
● Devascularization of the remnant parathyroid 
tissue: 
For 
primary 
hyperparathyroidism, 
parathyroid 
autotransplantation 
into 
sternocleidomastoid 
muscle 
should 
be 
undertaken. In the secondary or tertiary 
hyperparathyroidism, autotransplantation into 
the brachioradialis muscle (contralateral to the 
arteriovenous fistula,) Should be performed. 
Other options include the pectoralis and deltoid 
muscles. The reigning principle is to ensure 
creation of a muscle pocket, placement of the 
morcellated parathyroid tissue and closure of the 
overlying fascia with colored non-absorbable 
suture in a figure-of-eight to avoid spillage of 
parathyroid tissue and cells and successful 
autotransplantation 
 
Resection of Parathyroid Carcinoma:  
For surgical treatment of parathyroid mass, 
consider obtaining “4D” CT imaging in addition to 
US (and SESTAMIBI scan if available) to best 
delineate anatomic boundaries of the mass, 
dissection 
planes 
and 
potential 
areas 
of 
tracheoesophageal invasion 
that 
may require 
multidisciplinary intraoperative approach. En bloc 
resection of a parathyroid mass invading local 
structures should be undertaken. Make every effort 
through meticulous dissection to preserve the 
recurrent laryngeal nerve and parathyroid capsule to 
avoid spillage of parathyroid cells. 
 
Right Parathyroid Carcinoma Abuts the Right Recurrent 
Laryngeal Nerve. 
 
 
Resected specimen, right parathyroid carcinoma. 
 
Neck Exploration and Subtotal Parathyroidectomy 
Naira Baregamian 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
En Bloc Resection of a right parathyroid carcinoma invading 
the right thyroid lobe. Black silk suture denotes the course of 
the dissected and preserved right recurrent laryngeal nerve. 
 
Naira Baregamian, MD, MMS, FACS 
Vanderbilt University 
Tennessee, USA 
 
 
 
