Surgery for sporadic primary hyperparathyroidism: controversies and evidence-based approach

Sporadic primary hyperparathyroidism is due to single adenoma in over 90-95% of instances. Careful medical history and precise preoperative identification of the enlarged gland by parathyroid Tc-mibi scintigraphy and neck ultrasound allow selecting patients for minimally invasive parathyroidectomy, a focused intervention with minimal skin opening and tissue dissection. Small (<300 mg) adenomas continue to challenge preoperative imaging, and most of them will still require a bilateral exploration.

Surgery should never be indicated on the basis of positive or negative preoperative localization studies. Intraoperative quick parathyroid hormone measurements seem particularly helpful for cases with equivocal localization studies. The best minimal access approach is still a matter of debate, and options include small central incision, video-assisted parathyroidectomy, minimal lateral open approach, and purely endoscopic access via lateral approach. Radioguided surgery does not seem to have a role in routine cases but may be useful to find adenomas during reintervention on scarred difficult surgical fields.