Recent trends in the initial surgical treatment of primary hyperparathyroidism: a review

The standard treatment of primary hyperparathyroidism has long been, and for many surgeons still is, a cervicotomy with presentation of all parathyroid glands. The last two decades have been marked by a progress in localization and identification techniques, together with a general trend towards less invasive surgery. This evolution resulted in numerous and diverging new surgical strategies, all claiming to be as effective as the conventional neck exploration, but resulting in fewer complications and better cosmesis. We want to give an overview and a realistic positioning of these new techniques.

A literature search using PubMed from January 1980 to December 2000, combined with reference checking, identified the most important articles describing the new strategies. We present the evolution in the thinking, the data supplied, and our critical remarks.

The initial random unilateral exploration was followed by trials to achieve a more guided unilateral exploration. Different adjuncts developed can be classified as preoperative (isotope scanning, ultrasonography, computer tomographic scanning) and intraoperative (intraoperative intact parathyroid hormone measurement, intraoperative 99mTc sestamibi scanning). The surgical techniques using these adjuncts range from a classic collar type incision followed by a unilateral exploration, over external exploration (unilateral or bilateral) through a very small incision, to endoscopic neck exploration. Reported outcomes of these techniques are presented, and all aspects mentioned are labeled as T-1 (preoperative), T0 (intraoperative), or T + 1 (results and complications) features. The reported results seem to indicate there is a place for a less invasive approach, but should be interpreted with caution seeing the ever present selection bias in the described population.