Surgical anatomy of the parathyroid glands
- Melanie L Richards, MD
Melanie L Richards, MD
- MHPE Professor of Surgery
- Mayo Clinic College of Medicine
- Tracy S Wang, MD, MPH
Tracy S Wang, MD, MPH
- Associate Professor of Surgery
- Chief, Section of Endocrine Surgery
- Medical College of Wisconsin
- Julie Ann Sosa, MD, MA
Julie Ann Sosa, MD, MA
- Professor of Surgery and Medicine
- Chief, Section of Endocrine Surgery
- Leader, Endocrine Neoplasia Diseases Group
- Duke University Medical Center
The parathyroid glands were first identified by Sir Richard Owen in the Great Indian Rhinoceros in 1850 . They were identified in humans by Ivar Sandstrom, a Swedish medical student, in 1880 . The first parathyroidectomy was reported by Felix Mandl in 1929, 30 years prior to the isolation of human parathyroid hormone .
The success of the surgical management of parathyroid disease is based on accurate biochemical diagnosis and the surgeon's understanding of the significant embryologic variations in parathyroid anatomy. An expert knowledge of the unusual anatomic locations for enlarged parathyroid glands is crucial to operative success during both initial and reoperative parathyroid surgical exploration. The wide range of parathyroid anatomic variations may make it difficult to predict a patient's anatomy preoperatively.
Parathyroid anatomy is discussed here. The indications for parathyroidectomy, treatment of multiglandular disease, and surgical techniques are discussed elsewhere. (See "Primary hyperparathyroidism: Management", section on 'Candidates for surgery' and "Parathyroid exploration for primary hyperparathyroidism", section on 'Focused parathyroid exploration'.)
The parathyroid glands are usually in close approximation with, but function independently of, the thyroid gland. The parathyroid glands produce parathyroid hormone (PTH) which is one of the two major hormones modulating calcium and phosphate homeostasis; the other hormone is calcitriol (1,25-dihydroxyvitamin D). PTH also stimulates the conversion of calcidiol (25-hydroxyvitamin D) to calcitriol in renal tubular cells, thereby stimulating intestinal calcium absorption. The function and regulation of PTH and the diagnosis and management of hyperparathyroidism are discussed in detail elsewhere. (See "Parathyroid hormone secretion and action" and "Primary hyperparathyroidism: Diagnosis, differential diagnosis, and evaluation" and "Primary hyperparathyroidism: Management".)
The parathyroid glands arise from endodermal epithelial cells, in conjunction with the thymus (figure 1). The superior parathyroid glands are derived from the fourth branchial pouch. These glands are closely associated with the lateral lobes of the thyroid and have a short line of embryologic descent .
- Owen, R. On the anatomy of the Indian Rhinoceros (Rh. Unicornis, L). Trans Zool Soc Lond 1862; 4:31.
- Sandström, I. On a new gland in man and several mammals (glandulae parathyroideae). Ups Läk Förh 1880; 15:441.
- Mandl, F. Therapeutischer versuch bein einem falle von ostitis fibrosa generalisata mittels exstirpation eines epithelk orperchen tumors. Zentrabl Chir 1926; 5:260.
- Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg 2000; 24:891.
- Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands. Surgery 1984; 95:14.
- Wang C. The anatomic basis of parathyroid surgery. Ann Surg 1976; 183:271.
- Shen W, Düren M, Morita E, et al. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 1996; 131:861.
- Richards ML, Thompson GB, Farley DR, Grant CS. Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 2008; 196:937.
- Carter WB, Carter DL, Cohn HE. Cause and current management of reoperative hyperparathyroidism. Am Surg 1993; 59:120.
- Arveschoug AK, Brøchner-Mortensen J, Bertelsen H, Vammen B. Supernumerary parathyroid glands in recurrent secondary hyperparathyroidism. Clin Nucl Med 2002; 27:599.
- Edis AJ, Levitt MD. Supernumerary parathyroid glands: implications for the surgical treatment of secondary hyperparathyroidism. World J Surg 1987; 11:398.
- Flament, JB, Delattre, JF, Pluot, M. Arterial blood supply to the parathyroid glands: Implications for thyroid surgery. Surgical and Radiologic Anatomy 1982; 3:279.
- Jaskowiak N, Norton JA, Alexander HR, et al. A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 1996; 224:308.