Brief introduction of parathyroidectomy

Directory/KOOC-0/Pinyin 2 English Reference 3 Operation Name 4 Classification 5 Coding 6 Parathyroid Related Anatomy 7 Indications 8 Contraindications 9 Preoperative Preparation/KOOC-0/0 Anesthesia and * * */KOOC-0/Operation Steps/KOOC-0/2 Intraoperative Precautions/KOOC-0/3 Postoperative Treatment/KOOC-.

2 English reference parathyroidectomy

3 surgical name parathyroidectomy

4 classification general surgery/neck surgery/parathyroid surgery

5 ICD code 06.8 10 1

6 parathyroid anatomy parathyroid gland is formed by the proliferation of endoderm dorsal epithelium of the second and fourth branchial bursa during embryonic development. In the process of migration, the derivative of the third branchial sac developed into parathyroid gland located in the lower part of the posterior part of thyroid gland, and the fourth branchial sac evolved into upper parathyroid gland.

The parathyroid gland is a brownish yellow, bright chestnut or red oblate body like soybean. The weight of each parathyroid gland is about 35 mg. Attached to the posterior edge of the lateral thyroid lobe, mostly located outside the thyroid capsule, sometimes in the thyroid parenchyma. There are usually four parathyroids, each with a connective tissue capsule.

The connective tissue capsule of parathyroid gland is very thin, and this capsule extends into the gland tissue with tiny fibers. Arrange glandular cells in a rope or ball shape.

Main cells constitute the main body of parathyroid parenchyma and secrete parathyroid hormone. The physiological function of polygonal eosinophils has not been clarified.

The adipose tissue in parathyroid gland increases with age, and the content of adipose cells in adult is the highest, accounting for 50% of the gland.

The physiological function of parathyroid gland is mainly to secrete parathyroid hormone (PTH). The physiological function of PTH is to promote calcium ions to enter cells, activate intracellular adenosine cyclase, convert adenosine triphosphate into cyclic adenosine monophosphate (cAMP), and calcium ions escape from mitochondria, thus increasing the concentration of calcium ions in cell plasma. CAMP and calcium ions activate protein kinase and calcium pump on cell membrane, which can enhance osteoclast osteolysis, increase the activity of alkaline phosphatase in bone and blood, inhibit the reabsorption of phosphorus and calcium by proximal renal tubule, promote the hydroxylation of proximal renal tubule 25(OH)D3 to 1, 25 (OH) 2d3, and enhance the absorption of calcium, phosphorus and magnesium by intestinal mucosa.

Parathyroid hormone antagonizes calcitonin secreted by thyroid follicular cells, which is regulated by plasma calcium ion concentration to maintain the relative stability of blood calcium level.

In general, the upper parathyroid gland is located at the junction of upper middle 1/3 behind the two thyroid lobes, and its position is relatively constant. The following two parathyroids can move down with the thymus during embryonic development, and their positions change greatly. The common location is near the lower thyroid pole, the lower thyroid artery, the posterior esophagus or the anterior trachea along the upper mediastinum.

The blood supply of parathyroid gland comes from the arteriole branch extending from the communicating branch between the superior and inferior thyroid arteries, and it can also directly return to the middle and inferior thyroid venous plexus from the vein supplying parathyroid gland. The nerves of parathyroid gland come from sympathetic nerve fibers around vascular plexus. The lymph of parathyroid gland drains to the lymph node chain of paratracheal lymph node and internal jugular vein (figure1.1.7.101).

The position of parathyroid gland varies greatly. The upper two parathyroid glands are located near the hypothyroid pole (figure1.1.7.102a). The right upper parathyroid gland is located at the branch of the inferior thyroid artery, and the left lower parathyroid gland is embedded in the capsule outside the thyroid gland (figure1.1.7.102b). The upper two parathyroids are above the common position, and the lower two parathyroids are in front of the trachea (figure1.1.7.102c). There are two parathyroid glands above and below the right side, and the left parathyroid gland is fused into a larger parathyroid gland (figure1.1.7.102d). The left parathyroid gland atrophied, and the position of the upper and lower parathyroids on both sides changed (Figure1.1.7.102e).

About 1% of the lower ectopic parathyroid gland is located in the vascular sheath of the neck, 2% in the thyroid gland, 80% in the lower pole of the thyroid gland, within 2cm from the junction of the lower thyroid artery and recurrent laryngeal nerve, 20% in the upper pole of the thymus gland, and 1% under the aortic arch.

The abnormal position of the upper parathyroid gland is mostly behind the thyroid gland (figure 1. 1.7. 103) or in the posterior mediastinum (figure 1. 1.7. 104).

Adenomas or hyperplastic lesions of parathyroid gland are mostly located in the posterior part of upper esophagus (43%), above thymus (> 10%) or along great vessels (2%), mediastinum (> 10%) and included in thyroid (13%).

Adenoma of the lower parathyroid gland can be seen in carotid sheath (figure 1. 1.7. 105).

Indications Parathyroid resection is suitable for:

1. hypercalcemia, PTH concentration was determined by B-ultrasound, radionuclide scanning, CT selective arteriography and selective jugular vein intubation, and the patients were found to be positive.

2. The primary hyperparathyroidism is mostly adenoma (about 80%), followed by hyperparathyroidism, and parathyroid carcinoma only accounts for 1%. The patient suffers from hypercalcemia syndrome and diseases of digestive system, urinary system or musculoskeletal system, such as deformity of ribs, spine and hip, pathological fracture or severe bone pain.

Patients diagnosed as MEAⅰ(Werner syndrome, including gastrinoma, pituitary adenoma with parathyroid adenoma and gastrointestinal carcinoid) or MEA Ⅱ (Sipple syndrome, including pheochromocytoma and medullary thyroid carcinoma with hyperparathyroidism).

According to the determination of parathyroid function and the location diagnosis of parathyroid hyperplasia or tumor, it is found that the diameter of parathyroid is over 1 ~ 2 cm.

3. Patients with chronic renal insufficiency or secondary hyperparathyroidism due to renal failure who need kidney transplantation should undergo subtotal parathyroidectomy at the same time. Its significance lies in alleviating hypercalcemia caused by hyperparathyroidism for months or years after renal transplantation, which threatens the recovery of renal function.

4. In patients with fibrocystic osteitis, after laboratory examination, the parathyroid gland overreacted to its factor, and the gland gradually developed from hyperplasia to adenoma, showing that the blood calcium level increased obviously due to spontaneous secretion.

Severe bone pain with progressive fibrocystic osteitis has not improved after drug treatment and can be relieved after subtotal parathyroidectomy.

5. Parathyroid carcinoma with cervical lymph node metastasis, no distant metastasis.

8 contraindications 1. The disease has advanced and complicated with renal failure.

2. Parathyroid carcinoma has distant metastasis of lung, liver and bone.

9 preparation before operation 1. B-ultrasound and CT were performed to determine the location of parathyroid adenoma. Percutaneous subclavian arteriography, upper mediastinal pneumography, thallium and technetium radionuclide scanning and magnetic resonance imaging (MRI) were used to examine the parathyroid gland hidden behind the thyroid gland. When ultrasound examination is difficult to find, endoscopic ultrasound parathyroid localization can be done through esophagus. Ultrasonic waves are transmitted to the esophageal wall through the water sac placed around the sensor, and the parathyroid gland has low sound wave lesions.

2. Respond to the increase of myocardial sensitivity caused by hypercalcemia. Patients with arrhythmia should be treated before operation. Regulate the imbalance of body fluids. Correctly applying corticosteroids to reduce blood calcium. Patients with severe hypercalcemia need hemofiltration.

3. Parathyroid surgery requires fine vascular forceps, scissors and knives. So as to dissect slender blood vessels and other tissues around glands.

Cervical plexus anesthesia can be used for 10 anesthesia and simple adenoma resection. If a comprehensive exploratory operation is needed, endotracheal anesthesia is needed. The patient lies on his back, with a pillow under his shoulder, his head tilted back, and sandbags placed on both sides for fixation.

1 1 Operation steps 1 Surgical incision is the same as thyroidectomy (Figure 1. 1.7.6 1).

2. After separating the platysma myocutaneous flap, cut the white line of the neck through the midline and pull the hyoid muscle group to both sides. If the patient's neck is short and thick, the muscle can be transected as appropriate, which is beneficial to better expose the thyroid gland and parathyroid gland (figure 1. 1.7. 12).

3. First free one thyroid lobe, then explore the other gland as appropriate, and ligate and cut off the middle thyroid vein (figure 1. 1.7. 13).

4. Sew a thick nonabsorbing line in the middle of the thyroid lobe, and then pull the thyroid lobe inward, so that the parathyroid gland can be explored (Figure 1. 1.7. 14).

5. In the process of exploration, the surgical field should be kept free of blood and carefully dissected and separated to make the structure clear. It can first enter the thyroid gland from the branch of the inferior thyroid artery. Generally, the back of the right thyroid lobe is explored first. Because most adenomas occur in the right lower parathyroid gland, starting from the branch of the inferior thyroid artery, parathyroid gland is often located behind the inferior thyroid pole and in front of the inferior thyroid artery and recurrent laryngeal nerve. Because it is close to the nerve, it is best to identify the nerve before revealing the gland. Parathyroid gland is sometimes buried in the tissue of the lower thyroid pole, and sometimes lives near the lower thyroid artery. When the thyroid is pulled inward, the parathyroid gland does not shift with it (figure 1. 1.7. 15).

6. Then explore the back of the right lobe, near the upper pole and around the superior thyroid artery above the upper pole. The upper parathyroid gland is more constant and easier to find than the lower parathyroid gland. Usually located in the plane of the inferior margin of cricoid cartilage, between the thyroid and its capsule, near the posterolateral margin of esophagus. When the thyroid lobe is pulled forward and inward, the pea-sized brown parathyroid gland will be exposed. If the gland is smaller than normal, hyperparathyroidism will occur in other parathyroid glands (figure 1. 1.7. 16).

7. Finally, explore the anterior superior mediastinum under the lower pole until the sternum. The ectopic parathyroid tissue in the posterior mediastinum can be found in the connective tissue and adipose tissue in the neck of this area, or it can reach the chest cavity and live in the sulcus of pulmonary artery and aorta. When exploring, put your fingers into both sides of the trachea of the posterior mediastinum and you can feel abnormal nodules. If you detect a tumor, you can take it out, lift it up, put it into a neck incision, and tie a blood vessel at its pedicle. Most of its blood supply comes from the inferior thyroid artery (figure 1. 1.7. 17).

8. After exploring thyroid region and posterior mediastinum in normal position. Because parathyroid gland can be embedded in thyroid tissue, the operator must pay attention to the outside of the cervical thyroid pseudocapsule and the thyroid itself To explore this part, it is necessary to cut the thyroid pseudocapsule (anterior layer of deep cervical fascia and trachea) above the inferior thyroid artery 1cm, and the operator can probe into the back of this fascia with his fingers and explore it alone (Figure 1. 1.7. 18).

9. Ectopic parathyroid gland can exist in the tracheoesophageal groove, the anterior and posterior parts of upper mediastinum, and thyroid and thymus tissues. It is very important to accurately identify thyroid abnormalities during operation. Normal glands weigh 35 ~ 40 mg, with an average size of 5×3×2mm and a diameter of about 5mm, excluding surrounding fat. Soft and elastic, compressible and smooth. Abnormal glands can be swollen to 5 ~ 80 mm, weighing 0.4 ~ 120 g, round, hard, dark and incompressible, with little or no surrounding fat. Sometimes it is difficult to distinguish between glandular hyperplasia and adenoma with naked eye or microscope.

When adenoma is found, it should be differentiated from small thyroid cyst, small adenoma or enlarged lymph node. Therefore, pathological examination should be done during the operation.

After the adenoma is separated from the back of the thyroid gland, the vascular pedicle should be carefully ligated and cut off (Figure 1. 1.7. 19).

10. When parathyroid exploration is performed due to multiple parathyroid tumors, subtotal parathyroidectomy (that is, 3 parathyroid glands are removed) should be performed for patients with all 4 parathyroid glands swollen. If only 1 enlarged glands are found in patients with multiple endocrine tumor syndrome type I during operation, three and a half glands should be removed, although the rest are normal. Because the remaining parathyroid glands will continue to enlarge, hyperparathyroidism will recur. During the operation, all four parathyroids on both sides of the neck should be explored and those glands with abnormal size, texture, color and structure should be removed. Normal glands are observed with naked eyes without biopsy or resection.

The procedure of subtotal parathyroidectomy is to remove the two largest parathyroids, then remove one parathyroid gland with poor blood supply among the other two parathyroids, and finally partially remove the fourth parathyroid gland. The parathyroid parenchyma preserved in situ weighs 50 ~ 70 mg. A small metal clip can be placed at the stump of parathyroid gland for postoperative follow-up (Figure1.1.7.110).

1 1. If the parathyroid gland is simply removed without thyroid gland removal, the white line of the neck can be sutured with a thin thread below No.20 (Figure1.1.7.11), and the platysma myocutaneous flap can be sutured intermittently.

Neck dressing should not be too thick, so as not to affect the observation of neck swelling.

12 intraoperative precautions The symptoms of hyperparathyroidism can be caused by adenoma, hyperplasia or cancer, and the surgical methods are different. Therefore, it is necessary to find the diseased parathyroid gland in sequence and by region during operation. After finding it, quickly make frozen sections and take corresponding operations according to the results of pathological reports.

It is sometimes difficult to explore and find the diseased parathyroid gland during surgery. It is necessary to be familiar with the normal anatomical site of parathyroid gland and know the possible variation site. We must search carefully and patiently. If the lesion is not found in the normal position or neck, the anterior mediastinum or thymus must be explored. Thymus can be gradually separated from the depression of sternum stalk in neck incision from shallow to deep, and finally pulled out from behind sternum. If it is difficult to separate, the upper sternum can be split, and the thymus can be explored or removed.

No adenoma was found in the comprehensive exploration, so the parathyroid gland may be located in the thyroid gland. One side of the thyroid gland is obviously enlarged, so subtotal resection should be performed, and pathological examination should be made immediately. If the gland size is normal, it is necessary to cut the gland vertically from the upper pole to the lower pole for inspection.

Four parathyroid glands should be examined during operation. 80% patients can find 4 glands, 6% patients have 5 parathyroids, and patients with less than 4 parathyroids account for 14%. Single or multiple adenomas or hyperplasia can only be cured by removing enlarged glands.

In rare cases, the blood supply of the preserved parathyroid gland is extremely poor, and it may lose its vitality if it is left in place. Then take it out and cut it into small pieces and transplant it to sternocleidomastoid muscle.

If the pathological changes of parathyroid gland can't be diagnosed histologically, blindly removing a thyroid lobe often can't achieve the expected effect.

When parathyroid cancer is seriously adhered to the surrounding tissues, the scope of operation should be expanded, the involved muscles should be removed, and the tumor tissue adjacent to the tracheoesophageal groove should be removed. If parathyroid carcinoma with cervical lymph node metastasis is diagnosed, radical neck surgery should be performed as appropriate.

Postoperative treatment/After KLOC-0/3 parathyroidectomy, the following treatment was performed:

1. Patients were placed in a semi-recumbent position, and painkillers were used to reduce postoperative stress response. Morphines should not be used to avoid biliary and pancreatic diseases such as acute pancreatitis caused by Oddi sphincter spasm.

2. The airway should be kept unobstructed on 1 day after operation. Intubation injury during general anesthesia can lead to throat edema and airway obstruction. Emergency tracheotomy should be prepared.

3. Pay attention to the bleeding or hematoma of the neck wound compressing trachea or jugular vein for drainage. When there is a progressive hematoma, the incision suture should be removed in time to eliminate hematocele and explore the bleeding site.

4. The symptoms of hyperparathyroidism improved rapidly in patients with successful operation. Patients often have short-term hypoparathyroidism within 48 hours after operation, which is characterized by hypocalcemia and hypomagnesemia. Clinically, there are numbness around the lips, Chvostek positive sign and Trousseau sign. If you have mental symptoms, you should use sedatives appropriately.

5. Serum and urine calcium and phosphorus should be monitored after surgical resection of parathyroid adenoma and hyperplasia.

Blood calcium decreased at 6 ~12 hours after operation. Due to a large amount of calcium and phosphorus deposited on the decalcified bone after operation, the blood calcium can drop below the normal level 1 ~ 3 days after operation. It is characterized by numbness of the outlet lip and convulsions of limbs. Intravenous injection 10% calcium gluconate 10ml, 2-3 times a day. For patients who use digitalis and other drugs, ECG monitoring is needed when calcium is used to prevent arrhythmia. Adequate infusion helps to prevent calcium salts from depositing in renal tubules and renal parenchyma. Blood calcium and phosphorus mostly returned to normal within 1 ~ 2 weeks after operation.

In patients with hyperparathyroidism, the preoperative low phosphorus status may be further reduced.

Urine calcium and phosphorus normalized rapidly after operation. Patients with mild renal insufficiency can gradually recover from bone lesions after operation. The stones formed should be treated according to the principles of urology.

Patients with severe fibrocystic osteitis, peptic ulcer and other gastrointestinal complications should pay attention to the progress of this situation.

The contents of serum calcium and parathyroid hormone should be reduced to normal after radical operation of parathyroid cancer. If the above indexes rise again during follow-up, it is mostly caused by tumor recurrence or metastasis. If there is no downward trend of the above indexes after operation, it is proved that there are occult metastatic lesions that have not been cleared.

14 complications 1. Postoperative rebleeding can be caused by slippage of vascular ligature or rich blood supply to thyroid gland, fragile tissue, severe cough after operation, bleeding of gland section induced by swallowing or separation of ligature from blood clot. It usually occurs within 24 ~ 48 hours after operation, mainly manifested as local rapid swelling, tension, dyspnea and even suffocation.

The amount of bleeding is large, the neck swelling is aggravated, and the trachea is gradually compressed. The typical "three concave signs" are life-threatening emergency treatment due to suffocation, oxygen supply to alleviate hypoxia, and debridement and hemostasis after breathing is stable. Tracheal intubation or tracheotomy is performed when necessary.

2. The trachea sputum obstruction, laryngeal edema, tracheal softening or collapse, laryngotracheal spasm, critical condition, sputum suction effect is not good, emergency bedside tracheotomy should be performed. Because most of the thyroid gland has been removed and the trachea is in sight, the operation is not difficult. Incision of 1 ~ 2 tracheal cartilaginous ring, with hemostatic forceps to open the incision, sputum is naturally ejected, which can quickly relieve dyspnea.

Postoperative tetany: Tetany after operation is mostly caused by accidentally cutting or bumping parathyroid gland during subtotal thyroidectomy, or the blood supply of parathyroid gland is affected. The incidence of severe and persistent tetany is lower than 65438 0%. ?

Clinical symptoms usually appear 2 ~ 3 days after operation. Mild people have a sense of stiffness or numbness in the face or hands and feet, often accompanied by a sense of oppression in the precordial area. In severe cases, facial muscles and tetany appear. Severe cases are accompanied by laryngeal and diaphragmatic spasm, and even suffocation and death. During the interval of convulsion, the sensitivity of peripheral nerves and muscles increased, and the calcium content in blood mostly decreased to below 65438 0.996 mmol/L, and in severe cases to 65438 0.497 mmol/L, and the phosphorus content in blood increased to above 65438 0.937 mmol/L.

Thoroughly remove respiratory secretions, tracheal intubation regularly drip antibiotics or aerosol inhalation to prevent infection. If cerebral hypoxia occurs, it should be treated as usual, and the indwelling tracheotomy catheter should be removed after the condition is stable 1 ~ 2 weeks.

When tetany occurs, intravenous injection of 10% calcium gluconate solution can be used. Parathyroid tissue transplantation and parathyroid hormone have no definite effect. Dihydrosterol has therapeutic effect on tetany.

The parathyroid gland is slightly injured, and the slight tetany is easy to recover after operation, and the residual normal parathyroid gland can gradually enlarge and play a compensatory role.

3. 3 ~ 4 days after the operation of incision infection, the patient's body temperature rises and the wound is red, swollen and tender, which is a sign of incision infection. Extensive and deep infection spread to the larynx can cause dyspnea and even spread to the mediastinum. According to the scope and depth of infection, the incisions of each layer should be dismantled early, rubber plates should be placed for drainage, and antibiotics should be used in large quantities to control infection.

Sinus is formed at the incision, mostly due to deep knot, mild infection, or partial tissue necrosis of residual glands. If the sinus is deep, it needs to be cut to completely remove nodules and unhealthy granulation tissue.

Strict aseptic operation and thin nonabsorbable thread are effective measures to prevent incision infection and sinus formation.

Injury of recurrent laryngeal nerve can lead to dysphonia. The injury of recurrent laryngeal nerve is mostly due to unfamiliarity with the anatomy of the posterior medial area of thyroid, and another cause of injury is a large number of ligation when dealing with the blood vessels of the lower pole of thyroid. When one side of recurrent laryngeal nerve is injured, the vocal cord is on the midline side because it affects the adduction of cricothyroid muscle, and the sound changes. When the recurrent laryngeal nerve and the superior laryngeal nerve are injured, the vocal cords are in the middle position, resulting in hoarseness and inability to cough. In order to find out whether postoperative hoarseness is caused by surgical injury to recurrent laryngeal nerve, laryngoscopy should be done before operation.