PREOPERATIVE DIAGNOSES:
1. Chronic renal failure.
2. Secondary hyperparathyroidism.
POSTOPERATIVE DIAGNOSES:
1. Chronic renal failure.
2. Secondary hyperparathyroidism.
PROCEDURE PERFORMED: Subtotal parathyroidectomy with intraoperative PTH.
SURGEON: John Doe, MD
INDICATION FOR PROCEDURE: This is a (XX)-year-old female with chronic renal failure who presented with severe secondary hyperparathyroidism manifested by high calcium and phosphorus product and a high PTH level of over 1500 picograms/mL.
At the time of exploration, the patient was found to have 4 enlarged glands which were all removed except for one third of the left lower, which was left behind and marked by a clip. The PTH level at the end of the procedure was 225 picograms.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room for subtotal parathyroidectomy. The patient’s neck was entered with a transverse incision with a Kocher in the neck and was carried down with sharp dissection through skin and subcutaneous tissue down to the platysma. The platysma was isolated with sharp dissection.
Two flaps were raised, a superior and inferior flap. The superior and inferior flap and midline structures and muscles were divided in the midline. The right lobe of the gland was reflected medially. The tracheoesophageal groove was exposed. The inferior thyroid artery was seen.
The right lower parathyroid was seen behind the right lobe. This was found to be enlarged and was taken down to the blood supply, removed completely and sent to pathology. The right upper gland also was found in the tracheoesophageal groove behind the right upper lobe and was found to be moderately enlarged and was removed completely by taking the blood supply. The blood supply was clamped, ligated and transected. The right recurrent laryngeal nerve was seen and spared at all times.
Attention was directed to the left side, where the left tracheoesophageal groove was also seen. The left lower gland was seen and two thirds of the gland was excised and the site marked with a clip. The excised portion was removed and sent to pathology. In the same manner, the left upper gland was completely removed by means of sharp dissection down to the blood supply. Again, the left recurrent laryngeal nerve was seen and spared at all times.
All specimens were sent to pathology and confirmed to be hyperplastic parathyroid tissue. The PTH level, which at induction was over 1500 picograms, came back at 225.
The procedure, subtotal parathyroidectomy, was terminated. The air was drained with a TLS drain. The strap muscles were brought to the midline with interrupted 3-0 silk and the platysma with 4-0 silk and subcuticular 4-0 Monocryl. Steri-Strips were applied. The patient left the OR in stable condition.
