Strategies and Priorities in Parathyroid Surgery
What is important in parathyroid surgery and what is not?
This is a new page that we developed in an effort to clarify a number of issues that patients have raised with us recently.
Let’s start with a few really important things.
- Safety. Always priority #1.
Learn more about world-class quality and safety measures at UCLA hospital. This link has a very useful short video that brings you into the surgery environment to orient you to the detailed process we utilize for 100% of patients to ensure your safety. Furthermore, you can see our quality performance reports for patient satisfaction, patient safety, and patient survival compared to other hospitals. This information is provided by independent third parties such as the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).
- Success. Everyone wants a successful operation that is done right the first time and cures the disease permanently. As we have discussed, success rates are largely a function of surgeon and hospital experience (see Success rates of parathyroid surgery).
Compared to safety and success, other issues are much less important in the scheme of things. Next we will review a few items that are nonetheless still good to have.
- Excellent patient service. We want to deliver this to every patient, every time. As an organization, we believe that delivering compassionate and patient-centered care is essential to creating a healing environment. See the links below to learn about Dr. David Feinberg, CEO of UCLA Health System and the new book about patient satisfaction at UCLA, Prescription for Excellence, written by award-winning author Joseph Michelli (UCLA Endocrine Surgery is featured in the book).
- Incision length/size. All other things being equal, a small incision is nice to have. In general, a small incision indicates a less traumatic operation and bodes well for a speedy and relatively painless recovery. Again because of practice, expert surgeons can usually offer smaller incisions. The reason we put incision size somewhat lower down on this priority list is that, at present, there is really not much difference in the incision sizes offered by expert parathyroid surgeons. They are all around 1 inch (2.5 cm). We receive some questions about big parathyroid operations using incisions several inches long, and sometimes we meet patients from elsewhere with big scars that come to us for re-do parathyroid surgery. But incisions several inches long are generally a thing of the past and not worthy of too much discussion today. Sometimes patients see us for a second opinion after having been offered a 1-and-½-inch incision or perhaps a 2-inch incision by another surgeon with a good reputation. A difference of a few millimeters is largely cosmetic may not matter to many people, assuming the operation is safe and successful; that is up to the individual patient to decide. However, this being Los Angeles, we do pay attention to incision length and cosmetic appearance because the neck is a difficult part of the body to cover up, and a significant number of our patients make a living on camera (see our Scar gallery). Virtually all members of the American Association of Endocrine Surgeons offer parathyroid surgery through a small/mini incision (see Finding an expert parathyroid surgeon).
Okay, now let’s demystify a few things that are generally not very important, despite what you may have read elsewhere.
- Specific surgical approach to the parathyroids, or how many parathyroid glands are inspected during surgery. There are many ways to skin a cat. Indeed, every surgeon will have his or her own technique of performing parathyroid surgery. And that doesn’t matter. Experience does, as we have discussed at length already. So please do not let anyone convince you that their specific method is somehow superior. Here at UCLA we believe that there is no “one-size-fits-all” approach to parathyroid surgery (see Frequently asked questions about parathyroid surgery). Once again this is common sense. In most cases we believe it is beneficial to inspect more than 1 parathyroid gland, and often we inspect all 4. But of course this depends on the individual patient. And it is important to note that intraoperative parathyroid hormone (PTH) measurement is widely accepted as a beneficial adjunct in confirming cure in parathyroid surgery. However, intraoperative PTH, sestamibi scans, etc., as useful as they are, are all just tools for the surgeon. Ultimately parathyroid surgery is about surgical skill and surgical judgment (naturally this is true for all types of surgery), and that is the bottom line.
- Anesthesia type. We get a lot of questions about this. And the answer is always the same: we do what is safest for the patient. Many people are under the wrong impression that surgery under sedation is somehow better or safer than general anesthesia (going completely to sleep). There is no evidence to support that idea. Indeed, there are many circumstances where general anesthesia is safer. We were sufficiently interested in the topic of anesthesia for parathyroid surgery that we performed a prospective trial to evaluate three different anesthetic methods for parathyroid surgery: local anesthesia/numbing medicine plus sedation (also known as monitored anesthesia care or MAC), general anesthesia with a laryngeal mask airway (also known as LMA – this is a soft inflatable balloon that sits in the back of the mouth while the patient sleeps), and general anesthesia with endotracheal intubation (see References below). All three methods were equally safe and there were no anesthetic complications. Currently, the majority of our patients have general anesthesia with LMA during parathyroid surgery. This is a versatile and comfortable technique that is useful for most patients. But ultimately the choice of anesthesia type is made by the anesthesiologist after careful evaluation of the patient. We work with a regular subset of anesthesia faculty within the UCLA Department of Anesthesiology. These professionals have dedicated their careers to providing safe and excellent anesthetic care. We as surgeons are not going to second guess their expertise and neither should you (please). These are the same people who take care of us, our spouses, our children, and our friends when we need something done, and we cannot say enough about how outstanding our anesthesia doctors are. It is an honor to work alongside them.
- Speed or duration of the operation. Let’s face it, this is really not that important. Efficiency is a by-product of skill, practice, and collaborative systems improvement. Speed is not, in and of itself, a priority in surgery. The individual patient does not care how many other operations are done on the same day as their operation. The patient cares only that their operation is done safely and successfully. Indeed, time of surgery should not matter at all to the patient since they are sleeping regardless. The average operating time for parathyroid surgery at UCLA is about 20 minutes. Sometimes it takes longer, depending on the patient. Ultimately surgery takes as long as it takes to be done safely and successfully (this is common sense). Most experienced parathyroid surgeons can complete a parathyroid operation in under 1 hour. If a reputable surgeon tells you it might take longer than 1 hour, that is probably fine too, so long as the operation is safe and successful. Of course we like efficiency, but it ranks below all of the other important issues we have already listed. Honestly we don’t completely understand what all of the fuss regarding speed is about. We are here to take excellent care of each patient, one patient at a time. If one of us were to have surgery we would not want it to be rushed. So we are not going to rush your surgery. Enough said.
- Hong JC, Morris LF, Park EJ, Ituarte PH, Lee CH, Yeh MW. Transient increases in intraoperative parathyroid levels related to anesthetic technique. Surgery. 2011 Dec;150(6):1069-75. PubMed PMID: 22136823.
- Hwang RS, Morris LF, Ro K, Park S, Ituarte PH, Hong JC, Yeh MW. A selective, Bayesian approach to intraoperative PTH monitoring. Ann Surg. 2010 Jun;251(6):1122-6. PubMed PMID: 20485138.