Single-Gland Parathyroidectomy 
Courtney E. Gibson 
 
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  
 
Editor’s note: This technique requires a rapid 
(intraoperative) parathyroid hormone blood level 
assay, which is not usually available in resource-
limited settings. However we feel that this well-
written chapter will contribute to the reader’s 
understanding of the overall management of 
parathyroid disease.  
 
Introduction:  
Parathyroidectomy, or the surgical removal 
of diseased, overactive parathyroid tissue, is one of 
the most common endocrine surgical procedures 
performed annually. The most common indication 
for 
parathyroidectomy 
is 
primary 
hyperparathyroidism, or overactivity of one or more 
parathyroid glands that leads to the development of 
hypercalcemia, along with its consequent signs and 
symptoms. Primary hyperparathyroidism affects 
approximately 1 in 500 women over the age of 45 
years but can occur at any age and affect any gender. 
Some common signs and symptoms of 
primary hyperparathyroidism include bone pain, 
osteoporosis, 
nephrolithiasis 
(kidney 
stones), 
polyuria (frequent urination), and constipation. 
Neurocognitive symptoms, such as memory loss, 
poor concentration, mental fogginess, anxiety, and 
depression can also be associated with primary 
hyperparathyroidism. Primary hyperparathyroidism 
is typically due to the over secretion of parathyroid 
hormone by a single parathyroid gland (parathyroid 
adenoma); however, in some cases, all four glands 
are diseased (multigland hyperplasia).  
Minimally 
invasive 
parathyroidectomy 
involves the removal of a single, overactive 
parathyroid gland, and requires preoperative imaging 
for localization. Such imaging includes either a neck 
ultrasound, nuclear medicine scan, or parathyroid-
protocol CT scan. Subtotal parathyroidectomy is 
performed in patients who have multigland 
hyperplasia and will be described elsewhere in this 
atlas 
(see 
Neck 
Exploration 
and 
Subtotal 
Parathyroidectomy.) 
The general steps to minimally invasive, 
single gland parathyroidectomy include: 
● Making a transverse cervical incision above the 
clavicles 
● Mobilization and medial rotation of the 
ipsilateral thyroid lobe 
● Identification and isolation of the parathyroid 
adenoma 
● Isolation and division of the blood supply to the 
adenoma, followed by removal of the gland 
 
Steps: 
1. The patient is placed on the operating table, in 
either a supine, or semi-Fowler (“beach chair”) 
position. Either general anesthesia, or conscious 
sedation with local field block is provided. When 
general anesthesia is utilized, a specialized 
endotracheal tube that allows for nerve 
monitoring can be used; an esophageal tube 
and/or esophageal temperature probe are often 
inserted as well, to help identify the esophagus 
intraoperatively. A preoperative blood sample is 
sent to check the parathyroid hormone level 
before the start of the procedure. 
 
The Semi-Fowler “Beach Chair” position decreases venous 
congestion for operations in the neck.  
 
2. Using a fine scalpel (#15 blade,) make an 
approximate one-inch (2.5–3.5-cm) transverse 
cervical (Kocher) incision in the midline of the 
neck, one to two fingerbreadths above the sternal 
notch (depending on the length of the patient’s 
neck area). This is followed by the development 
of subplatysmal flaps. 
Single-Gland Parathyroidectomy 
Courtney E. Gibson 
 
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  
 
 
This picture from a thyroidectomy shows the subplatysmal flaps 
in a cranial (shown) and caudal direction after skin incision. 
Note that at the midline, this plane is fibrous and not muscular. 
Source: Eugenio Panieri and Johan Fagen- 
https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-
48e5-81be-586fbaeba29d/Thyroidectomy.pdf 
 
3. Open the median raphe, an avascular plane of 
connective tissue separating the left and right 
strap muscles. Dissect between the strap muscles 
and the anterior surface of the thyroid gland. 
 
The sternothyroid and sternohyoid muscles (also known as the 
strap muscles) meet at the midline just over the trachea: 
division at the midline allows the trachea to be reached in a 
relatively bloodless plane. 
 
4. Next, the ipsilateral thyroid lobe is grasped with 
a clamp, and pulled medially, toward the trachea. 
This maneuver exposes the middle thyroid vein, 
which is then ligated and divided. The thyroid 
lobe is then further retracted medially, to expose 
the tracheoesophageal groove, where 
the 
recurrent laryngeal nerve lies. The recurrent 
laryngeal nerve is then carefully dissected free 
from surrounding tissue and preserved. 
 
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.  
 
 
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  
 
5. At this point, the parathyroid adenoma is 
searched for. Under normal circumstances, the 
Single-Gland Parathyroidectomy 
Courtney E. Gibson 
 
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  
 
upper and lower parathyroid glands are located 
approximately 1 cm above or below the 
intersection of the recurrent laryngeal nerve and 
the inferior thyroid artery. Once the abnormal 
parathyroid gland is found, it is carefully 
dissected free from the surrounding tissue, its 
pedicled blood supply is identified and divided, 
and the parathyroid gland is removed. 
 
Right inferior parathyroid adenoma removed during single 
gland parathyroidectomy. The  thyroid gland (Green dot) was 
retracted medially, allowing visualization and dissection of the 
adenoma. The internal jugular vein is shown by a Blue dot. 
Photo courtesy of Dr. Chege Macharia.  
 
6. At this point, the parathyroid hormone level is 
again checked with several blood samples. The 
goal is to make sure that the level has dropped by 
at least 50% of its baseline level, and into the 
normal range. Once this is achieved, the area is 
irrigated thoroughly and suctioned dry, to ensure 
that hemostasis is achieved. The surgical wound 
is closed in layers with absorbable suture, and a 
sterile dressing is applied. 
 
Pitfalls 
● Mishandling of abnormal parathyroid tissue can 
lead to a condition called parathyromatosis. In 
this 
condition, 
foci 
of 
hyperfunctioning 
parathyroid tissue form in the neck and 
mediastinum. This is a rare cause of recurrent 
hyperparathyroidism. It is felt to occur from 
seeding after rupture of the parathyroid gland 
capsule during surgical removal of a parathyroid 
adenoma. Most adenomas still have a remnant of 
normal parathyroid tissue, along with some 
fibrofatty tissue; it is important to grab the 
abnormal parathyroid gland in this area, to avoid 
piercing the capsule of the tumor, and thereby 
causing leakage (or seeding) of hyperfunctioning 
parathyroid cells. 
● Misinterpretation of the intact parathyroid 
hormone (iPTH) assay: For minimally invasive 
single-gland 
parathyroidectomy, 
iPTH 
assessment is crucial to ensuring all diseased 
parathyroid tissue is removed. Many describe a 
50% drop in the iPTH level from baseline (from 
the value obtained prior to the start of the 
procedure), 
as 
adequate 
assurance 
that 
biochemical cure has been achieved. However, 
often the initial value is significantly high enough 
that a 50% drop would still leave the iPTH value 
above the normal range. For these reasons, it is 
recommended that iPTH blood levels be obtained 
beyond 10 minutes post-excision, to at least 15 to 
20 minutes. If the levels fall into (and stay in) the 
normal range, the procedure can be completed. 
However, if the levels start to rise at the 15–20-
minute time point, this suggests that additional 
parathyroid 
glands 
are 
abnormal 
(hyperfunctioning), 
and 
therefore 
further 
exploration and excision is required. 
● Inability to find the abnormal parathyroid gland: 
There are typical locations where upper and 
lower parathyroid glands are found in the neck- 
usually within 1 cm above or below the 
intersection of the recurrent laryngeal nerve and 
inferior thyroid artery. In many cases, abnormal 
parathyroid tissue can be found in ectopic 
(unusual) locations. Some of these locations 
include (but are not limited to):  
• The cervical horn of the thymus,  
• Within the carotid sheath,  
• Intrathyroidal,  
• Paraesophageal,  
• Prevertebral 
• Undescended (at the level of the hyoid 
bone or laryngeal muscles).  
It is imperative that a parathyroid surgeon have 
expert knowledge of these ectopic locations, so 
as not to have a failed procedure. For more 
information on this situation, see “Neck 
Exploration and Subtotal Parathyroidectomy.” 
Single-Gland Parathyroidectomy 
Courtney E. Gibson 
 
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 paraesophageal left upper parathyroid adenoma, which is a 
common location for an ectopic upper gland. 
 
 
Potential ectopic parathyroid locations, for both superior and 
inferior glands. Source: http://www.endocrinesurgery.net.au, 
used with permission. 
 
● Recurrent laryngeal nerve (RLN) injury is rare in 
parathyroid surgery, but can be devastating, 
leading to significant voice changes in the patient 
that may sometimes be permanent. Expert 
knowledge of the location of the recurrent 
laryngeal nerve, and its relationship to the blood 
supply to the parathyroid glands is important to 
minimize risk of injury to this important nerve. 
In most cases, the blood supply to the inferior 
parathyroid glands courses anterior to (in front 
of) the RLN; therefore, inferior parathyroid 
adenomas are often encountered before the RLN 
is even identified, and the nerve is therefore at 
minimal risk of injury when removing inferior 
glands. In contrast, the blood supply to the 
superior parathyroid glands typically course 
posterior to (behind) the RLN. Therefore, 
identification of the RLN prior to searching for 
an upper gland is the best way to avoid nerve 
injury. 
 
The association between the blood supply to an upper 
adenoma and the recurrent laryngeal nerve (shown by the 
Black pointer.) The blood supply for upper glands typically 
courses beneath the nerve, which is important to know when 
dissecting out upper parathyroid adenomas. 
Single-Gland Parathyroidectomy 
Courtney E. Gibson 
 
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. 
 
Courtney E. Gibson, MD, MS, FACS 
Yale University 
Connecticut, USA 
 
 
