Parathyroidectomy

The physiological function of the parathyroid glands is mainly the secretion of parathyroid hormone (PTH). The physiological role of PTH is to promote the entry of calcium ions into cells and activate intracellular adenylate cyclase, which converts adenosine triphosphate into cyclic adenosine monophosphate (cAMP), which causes calcium ions in the mitochondria to escape, thereby increasing the intracellular calcium concentration. cAMP, calcium-activated protein kinase and calcium pump on the membrane enhance osteolysis of osteoclasts, increase alkaline phosphatase activity in bone and blood, inhibit reabsorption of phosphorus and calcium by proximal tubules, and promote near Hydroxylation of endothelium 25(OH)D3 into 1,25(OH)2D3 enhances the absorption of calcium, phosphorus and magnesium by the intestinal mucosa. Parathyroidectomy is a surgical technique commonly used for parathyroid adenomas. Treatment of diseases: hyperparathyroidism, primary hyperparathyroidism Indication 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. Position: supine position, high shoulders, so that the head is tilted back to fully reveal the neck; the sides of the head are fixed with small sandbags to prevent the head from moving to the left and right to infiltrate the incision. 2. Incision: 2 transverse fingers above the sternum, arc-shaped incision along the dermatoglyph, the two ends reach the outer edge of the sternocleidomastoid muscle; if the gland is larger, the incision can be extended upward and upward. The skin, subcutaneous tissue and platysma were cut open, and the upper and lower flaps were pulled with tissue forceps, and separated by loose knives between the loose tissues behind the platysma, up to the lower edge of the thyroid cartilage, and the sternal stem was cut. This gap has fewer blood vessels, and it is often easy to bleed when it is too deep or too shallow. The incision was protected with a sterile towel, the incision was pulled with a small hook, and the anterior cervical veins were sutured with a 4 gauge wire. 3. Check the parathyroid gland: (1) First explore the normal location of the four parathyroid glands. Start with the right thyroid gland, cut and ligation of the right thyroid vein. Use the hemostatic forceps or traction line to pull the thyroid gland inward and forward, bluntly separate the loose tissue from the lateral side of the right lobe, and reach the esophageal and cervical fascia, which can be in the dorsal thyroid, the superior thyroid artery and the lower thyroid artery. The distribution area saw two parathyroid glands or adenomas on the right side. The normal parathyroid glands are orange-yellow, oval, about 5 mm × 3 mm × 2 mm, and two on the left and right sides. For example, one of the glands is reddish-brown and mostly adenoma, which is easy to be found. If more than two glands are larger than normal and the size is not uniform, the color is yellow reddish brown, then it should be considered as hyperplasia. Parathyroid carcinoma is mostly round, grayish white due to thickening of the capsule, often with adhesion between the surrounding tissue. If no suspicious lesions or hyperplasia are found on the right side of the probe, the left side should be explored. (2) Exploration of ectopic parathyroid adenoma: usually divided into three anatomical regions. a. Cervical thyroid region; b. Posterior region of the sternum; c. Upper mediastinum, need to open the sternum to explore the thymus. It can also be searched for the variant parts of the process of embryogenesis of the upper and lower parathyroid glands. There are 4 abnormal parts of the upper parathyroid gland and 5 abnormal parts of the lower parathyroid gland. If the neck can not find the diseased gland, the sternum should be opened to explore the upper mediastinum or thymus. If necessary, the thymus can be removed for dissection and looking for lesions. Because the para-adenoma in the mediastinum is almost in the thymus. 4. Remove the parathyroid gland from the lesion: (1) Adenomas are bluntly separated from the surrounding tissues, and the blood vessels are cut and ligated, and the adenomas are completely removed. (2) Resection of hyperplastic parathyroid glands: If the exploration reveals that more than 2 paragonads are obviously enlarged, it can be judged as hyperplasia. After exploring 4 pieces, select one of them to cut the tissue and send frozen slices. When the pathology is confirmed to be hyperplasia, 3 pieces can be removed, leaving only one paragland of not more than 40 mg to maintain normal function. (3) If the diagnosis of parathyroid carcinoma, the ipsilateral thyroid leaves and isthmus and the common carotid artery loose connective tissue, peri-tracheal fat tissue and lymph nodes should be removed together. If the cancer capsule is not broken, the recurrent laryngeal nerve can be retained. If the tumor has collapsed or adhered or infiltrated with the recurrent laryngeal nerve, it should be removed together. 5. Suture the anterior cervical muscle and skin incision: After the removal of the parathyroid adenoma, the wound is reliably sutured to stop bleeding. The incision can be sutured without drainage. For parathyroid hyperplasia or para-adenocarcinoma, the operation range is wide, the wound surface is large, and the rubber sheet or rubber tube should be placed for drainage. 6. Drainage and suture incision: After suturing the bilateral thyroid gland completely, hemorrhage was applied to the wound surface with hot saline gauze. At this time, the patient's shoulder pad is taken out to facilitate the patient's neck to relax, remove the hot saline gauze; check the bleeding point, see the entire wound without bleeding, in the left and right glandular fossa, respectively, the tube-shaped rubber sheet Or a thin drainage tube with a diameter of 3 to 5 mm, which is taken out from the inner edge of the sternocleidomastoid muscle and the incision and fixed. The incision is sutured layer by layer. complication 1. Postoperative hemorrhage: postoperative vascular ligation line slippage or thyroid blood supply is rich, tissue is fragile, postoperative severe cough, swallowing action induces oozing of gland cut surface, or ligation line and blood clot detachment can cause surgery After bleeding. It usually occurs within 24 to 48 hours after surgery, mainly manifested as local swelling, tension, difficulty breathing, and even suffocation. The amount of bleeding is large, the swelling of the neck is aggravated, the trachea is gradually compressed, and the typical "three concave sign" appears. The first-aid treatment is endangered by suffocation, and the oxygen is relieved to relieve hypoxia. Stop bleeding. Tracheal intubation or tracheotomy if necessary. 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. Postoperative hand and foot spasm: more than due to thyroidectomy, the parathyroid gland was mistakenly removed or contused, or the blood supply to the parathyroid gland was caused by postoperative hand and foot spasm. The incidence of severe and persistent hand, foot and ringworm is below 1%. Clinical symptoms often appear 2 to 3 days after surgery. Lighter people have a strong sense of straightness or numbness on the face or hands and feet, often accompanied by a feeling of pressure in the precordial area. In severe cases, facial muscles and hand and foot spasms occur. Severe cases are also associated with larynx and diaphragmatic spasm, and even suffocation to death. During the interval of sputum, the stimulation of peripheral nerves and muscles increased, and the calcium content in blood decreased to 1.996mmol/L or less. In severe cases to 1.497mmol/L, the phosphorus content in blood increased to 1.937mmol/L. More. Thoroughly remove respiratory secretions, the tracheal tube should be instilled with antibiotics or aerosol inhalation to prevent infection. If combined with cerebral hypoxia, routine treatment should be performed. The indwelling tracheotomy catheter should be removed 1 to 2 weeks after the condition is stable. At the onset of sputum, a 10% calcium gluconate solution can be administered intravenously. Parathyroid tissue transplantation and parathyroid hormone have no clear effect. Dihydrogenated sterols have a therapeutic effect on athlete's foot. Mild parathyroid injury, slight hand, foot and ankle are easy to recover after surgery, and the residual normal parathyroid glands can be gradually enlarged and compensatory. 3. Incision infection: 3 to 4 days after surgery, the patient's temperature rises, redness and tenderness around the incision, which 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. There is a sinus formation at the incision, mostly due to the presence of a knot in the deep, combined with mild infection, or necrosis of part of the residual gland. If the sinus is deep, it should be cut open to completely remove the knot and unhealthy granulation tissue. Strictly performing aseptic procedures and applying finer non-absorbent lines as much as possible is an effective measure to prevent wound infection and sinus formation. Damage to the recurrent laryngeal nerve can lead to vocal dysfunction. The cause of recurrent laryngeal nerve injury is mostly due to the unfamiliarity of the posterior and posterior thyroid gland. The other cause of the injury is to make a large ligation when treating the thyroid gland. When one side of the recurrent laryngeal nerve is injured, the vocal cords are in the midline position due to the influence of the adductor retraction. The sound changes. The vocal cords are in the middle position when one side of the recurrent laryngeal nerve and the superior laryngeal nerve are injured, resulting in hoarseness and inability to cough. In order to clarify the hoarseness after surgery, whether it is caused by surgical injury to the recurrent laryngeal nerve, a laryngoscopy should be performed before surgery.