Should Your Parathyroid Surgeon Look at All 4 Parathyroid Glands?

When you're facing parathyroid surgery for hyperparathyroidism, you might hear conflicting advice about surgical technique. Some surgeons insist on examining all four parathyroid glands during every operation. Others advocate for a more targeted approach, removing only the clearly abnormal gland(s). So which is right?

The answer, like many things in medicine, is nuanced: it depends on your specific situation.

Understanding the Traditional 4-Gland Exploration

Historically, parathyroid surgeons performed what's called a "bilateral neck exploration" – systematically identifying and examining all four parathyroid glands during surgery. This approach made sense decades ago when we had limited ability to identify which gland was causing problems before surgery.

The logic was straightforward: if you look at all four glands, you won't miss anything. And in certain situations, this remains absolutely the right approach.

When Looking at All 4 Glands Is Necessary

There are specific circumstances where examining all four parathyroid glands is not just recommended – it's essential:

Parathyroid Hyperplasia: When all four glands are enlarged (multigland disease), you need to identify each one to make the right surgical decision. This occurs in about 15-20% of primary hyperparathyroidism cases and is more common in hereditary syndromes like MEN1 or MEN2A. If your surgeon only removes one gland when you actually have hyperplasia, your calcium will remain elevated and you'll need another operation.

Failed Previous Surgery: If you've had unsuccessful parathyroid surgery before, the anatomy is often distorted by scar tissue. A comprehensive exploration may be necessary to find the abnormal gland that was missed the first time.

Negative or Discordant Preoperative Imaging: When sestamibi scans, ultrasound, and CT scans fail to identify an abnormal gland or show conflicting results, a more thorough surgical exploration is warranted.

Familial Hyperparathyroidism: Patients with genetic syndromes have different patterns of disease that typically require evaluation of all glands.

The Evolution: Focused Parathyroidectomy

Over the past two decades, advances in preoperative imaging have transformed parathyroid surgery. High-resolution ultrasound and sestamibi scanning can now identify single abnormal glands with impressive accuracy – often 85-95% in experienced hands.

This has enabled what we call "focused" or "minimally invasive" parathyroidectomy. When preoperative studies clearly identify a single enlarged gland (an adenoma), and intraoperative PTH testing confirms cure after removing that gland, there's often no need to search for and examine the other three normal glands.

Why Focused Surgery Can Be Better

When appropriate, focused parathyroidectomy offers several advantages:

Reduced Operative Time: Shorter surgery means less anesthesia exposure and faster recovery.

Lower Risk of Complications: Every normal parathyroid gland you manipulate carries a small risk of devascularization (cutting off its blood supply), potentially causing temporary or permanent hypoparathyroidism. If three glands are normal and working well, why risk disturbing them?

Smaller Incisions: Targeted approaches often allow for smaller, more cosmetic incisions.

Faster Recovery: Less tissue dissection typically means less postoperative discomfort and quicker return to normal activities.

The Critical Distinction: Expertise Matters

Here's what many patients don't realize: the debate over 4-gland exploration versus focused surgery isn't really about which technique is "better" in absolute terms. It's about surgical judgment and expertise.

An experienced, high-volume parathyroid surgeon understands when to use each approach. They know how to interpret preoperative imaging, they understand the patterns of disease, and they can adapt their surgical plan based on what they find during the operation.

The surgeon who dogmatically insists on examining all four glands in every patient may be causing unnecessary risk to normal glands. But the surgeon who performs focused surgery without proper preoperative workup or intraoperative PTH monitoring may be leaving disease behind.

What to Look for in Your Parathyroid Surgeon

Instead of asking whether your surgeon "always" looks at all four glands, ask better questions:

• How do you determine which surgical approach to use for each patient?
• What preoperative imaging do you require?
• Do you use intraoperative PTH monitoring?
• What's your cure rate for first-time surgery?
• How often do patients need reoperation?
• What's your rate of complications like hypoparathyroidism or recurrent laryngeal nerve injury?
• What will the scar look like? Are there other surgical approaches that could make the scar look even better?

A surgeon who can explain their decision-making process and demonstrate excellent outcomes using individualized surgical planning is far more valuable than one who follows a one-size-fits-all protocol.

The Bottom Line

Should your parathyroid surgeon look at all four glands? Sometimes yes, sometimes no.

What matters most is that your surgeon has the expertise to make that decision correctly for YOUR specific situation. They should be performing enough parathyroid operations to maintain proficiency (we're talking at least 50+ per year, ideally many more). They should use modern imaging and intraoperative tools. And they should have the judgment to know when a focused approach is safe versus when comprehensive exploration is necessary.

At the Russell Center for Endocrine Health, we individualize the surgical approach based on each patient's preoperative workup, imaging findings, and disease pattern. We use focused surgery when appropriate, but we're prepared to perform comprehensive exploration when the clinical situation demands it. This combination of advanced technique and surgical judgment is what allows us to achieve cure rates above 99% while maintaining the lowest possible complication rates. And... we can usually do it without a visible scar.

The question isn't whether all four glands should be examined. The question is whether your surgeon has the expertise to make the right decision.

Dr. Jon Russell is a Johns Hopkins-trained endocrine surgeon specializing in thyroid and parathyroid surgery. He serves on the American Thyroid Association Guidelines Committee and is the 2024 President of the North American Society for Integrated Thyroid Surgery. The Russell Center for Endocrine Health is located in Columbia, Maryland.

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