Parathyroid exploration, parathyroidectomy (primary hyperthyroidism)

Treatment of diseases: hypercalcemia hyperthyroidism Indication Parathyroidectomy is applicable to: 1. Hypercalcemia, B-ultrasound, radionuclide scanning, CT selective angiography, selective jugular vein intubation blood sampling to determine the concentration of PTH, patients with positive findings. 2. Primary hyperparathyroidism, mostly adenoma (about 80%), followed by parathyroid hyperplasia, and parathyroid cancer only accounted for 1%. The patient has hypercalcemia syndrome and disorders of the digestive system, urinary system or musculoskeletal system such as ribs, spine, hip bone deformity, pathological fracture or severe bone pain. Diagnosed as MEA-I (Werner syndrome, including gastrinoma, pituitary adenoma with parathyroid adenoma, gastrointestinal carcinoid) or MEA-II (Sipple syndrome, including pheochromocytoma, thyroid medulla Patients with cancerous tumors with hyperparathyroidism). According to the measurement of parathyroid function and the diagnosis of parathyroid hyperplasia or tumor, the diameter of the parathyroid gland is more than 1 to 2 cm. 3. Chronic renal insufficiency or renal failure secondary hyperparathyroidism, patients requiring renal transplantation, should be subtotal subtotal resection in renal transplantation. The significance is to alleviate the recovery of renal function due to hypercalcemia caused by hyperparathyroidism within a few months or years after kidney transplantation. 4. Patients with fibrotic cystic osteoinflammation, laboratory examination of the parathyroid gland overreaction to its stimulating factors, gland gradually developed from a hyperplasia to adenoma, manifested as autonomous secretion leading to a significant increase in blood calcium levels. Severe bone pain has progressive fibrocystic osteitis, and there is no improvement after medical treatment. After subtotal parathyroidectomy, the above symptoms may be relieved. 5. Parathyroid carcinoma has cervical lymph node metastasis and there is no distant metastasis. Contraindications 1. The condition has progressed to the advanced stage and combined with renal failure. 2. Parathyroid carcinoma has occurred in distant metastasis such as lung, liver and bone. Preoperative preparation 1. Do B-ultrasound, CT examination, and determine the location of parathyroid adenoma. Percutaneous subclavian artery angiography, upper mediastinal angiography or sputum-sputum radionuclide scan and magnetic resonance imaging (MRI) were performed to examine the parathyroid gland behind the thyroid gland. When the ultrasound examination is difficult to find, the endoscopic ultrasound parathyroid localization examination of the transesophage can be performed. Ultrasound is transmitted to the esophageal wall by a water bladder placed around the sensor, which appears as a low-sound lesion at the parathyroid glands. 2. Treatment of hypercalcemia caused by increased myocardial sensitivity. Those with arrhythmia should be treated accordingly before surgery. Adjust body fluid imbalance. Appropriate application of corticosteroids reduces blood calcium. Hemofiltration is required in patients with severe hypercalcemia. 3. Parathyroid surgery requires a relatively fine vascular clamp, scissors, knife, etc. to facilitate the dissection of the fine blood vessels and other tissues around the gland. Surgical procedure 1. Surgical incision with thyroidectomy. 2. After separating the flap under the platysma muscle layer, the white line of the neck is cut through the midline, and the sublingual muscle group is pulled to the sides. If the patient's neck is short and thick, the muscle can be transected as appropriate, which is beneficial to better reveal the thyroid gland and parathyroid glands. 3. Free one side of the thyroid leaf and then explore the other side of the gland as appropriate, ligation, and cut off the thyroid vein. 4. Slot the thick non-absorbent line in the middle of the thyroid leaf and pull the gland leaf inward to begin exploration of the parathyroid gland. 5. During the exploration process, the surgical field should be kept blood-free and carefully dissected to make the structure clear. It can be branched from the lower thyroid artery into the thyroid gland. Generally, the back of the right lobe of the thyroid gland is first explored. Since most adenomas occur in the parathyroid gland at the lower right side, starting from the branch of the inferior thyroid artery, the parathyroid gland is often located behind the inferior thyroid gland, the inferior thyroid artery and the recurrent laryngeal nerve. The front. Because it is close to the nerve, it is best to identify the nerve before revealing the gland. Sometimes the parathyroid glands are buried in the tissues of the lower extremities of the thyroid gland, sometimes in the vicinity of the inferior thyroid artery. When the thyroid gland is pulled forward, the parathyroid glands do not shift. 6. Then explore the back of the right lobe, near the upper pole and above the upper thyroid artery. The upper parathyroid gland is more constant than the lower one, and it is easier to find, usually at the lower edge of the cartilage, between the thyroid gland and its capsule, and close to the posterior lateral edge of the esophagus. When the thyroid leaves are pulled forward, the brown-yellow parathyroid glands, such as peas, are exposed in front of the eyes. If the glands are smaller than normal, the hyperparathyroid tumors that function hyperthyroidism occur in other parathyroid glands. 7. Finally, explore the anterior superior mediastinum below the lower pole until the sternum. The ectopic parathyroid tissue in the posterior mediastinum can find small island-like parathyroid tissue in the connective tissue and adipose tissue of the neck in this region, or can be found in the sulcus of the pulmonary artery and the aorta as low as the thoracic cavity. During the exploration, the fingers will be probed into the posterior mediastinal trachea. It may touch abnormal nodules. If the tumor is explored, it can be freed, lifted up into the neck incision, and the blood vessels of the pedicle are ligated. Mostly from the lower thyroid artery. 8. Explore the thyroid area and posterior mediastinum in the normal position. Because the parathyroid glands can be embedded in the thyroid tissue, the operator must pay attention to the outside of the thyroid pseudocapsule of the neck and the thyroid itself. When exploring this part, the pseudo capsule of the thyroid (the anterior tracheal layer of the deep fascia of the neck) should be cut 1 cm above the lower thyroid artery. The operator can use his fingers to probe into the back of the fascia and explore separately. 9. The ectopic parathyroid glands may be present in the tracheal esophageal sulcus, in the anterior and posterior mediastinum, in the thyroid gland and thymus tissue. It is important to accurately identify abnormal thyroid during surgery. Normal gland body weight 35 ~ 40mg, remove the surrounding fat, the average size of 5 × 3 × 2mm, diameter of about 5mm. The texture is soft and elastic, compressible and smooth. Abnormal glands can be increased to 5 ~ 80mm, weight 0.4 ~ 120g, the shape is rounder, harder, darker, can not be compressed, less or no surrounding fat. Sometimes it is difficult to identify glandular hyperplasia or adenoma by the naked eye or under the microscope. When adenomas are found, they should be differentiated from small cysts of the thyroid gland, small adenomas or enlarged lymph nodes. Therefore, pathological biopsy should be performed during surgery. After the adenoma is isolated from the back of the thyroid gland, the vascular pedicle should be carefully ligated and severed. 10. For parathyroid gland exploration of multiple parathyroid adenomas, patients with 4 hyperparathyroid glands should be treated with subtotal parathyroidectomy (ie, removal of 3 semi-parathyroid glands). In patients with multiple endocrine neoplasia syndrome type I, if only one enlarged gland is found during surgery, the rest are normal, and three semi-glands should be removed. Because the rest of the parathyroid glands continue to increase and the hyperparathyroidism relapses. During surgery, all four parathyroid glands on both sides of the neck should be examined to remove glands that are abnormal in size, texture, color and structure. Normal glands were visually observed without biopsy or resection. The procedure for subtotal resection of the parathyroid gland is to first remove the two largest parathyroid glands, and then cut a parathyroid gland with a poor blood supply in the other two parathyroid glands, and finally the fourth parathyroid gland. Partial resection. The parathyroid gland retained in situ is 50-70 mg in weight. Small metal clips can be placed on the parathyroid stump for follow-up after surgery. 11. Simple parathyroidectomy, without thyroidectomy, can not place drainage, use the thin line below 2-0 to suture the neck white line, intermittently suture the platysma muscle flap and skin. complication 1. Postoperative rebleeding due to vascular ligation line slippage or thyroid blood supply is rich, tissue fragility, postoperative severe cough, swallowing action induces oozing of glandular cut surface, or ligation line and blood clot detachment can cause postoperative Bleeding. It usually occurs within 24 to 48 hours after surgery, mainly manifested as local swelling, tension, difficulty breathing, and even suffocation. 2. Intratracheal sputum obstruction, laryngeal edema, tracheal softening or collapse, laryngeal, tracheal fistula, critically ill, when the sucking effect is not good, emergency bedside tracheotomy should be performed. Because the thyroid has been mostly removed, the trachea is in the field of view, and the operation is not difficult. Cut 1 or 2 tracheal cartilage rings, use a hemostatic forceps to open the incision, and the sputum is naturally ejected, which can quickly relieve breathing difficulties. 3. Incision infection 3 to 4 days after surgery, the patient's body temperature increased, redness around the incision, tenderness, is a sign of wound infection. Extensive, deep infections that spread to the throat can cause breathing difficulties and even extend to the mediastinum. According to the extent and depth of the infection, the layers of the incision were disassembled at an early stage, and a rubber sheet was placed for drainage, and a large amount of antibiotics were applied to control the infection.