In situ preservation of parathyroid glands:advanced surgical tips for prevention of permanent hypoparathyroidism in thyroid surgery.

Hypoparathyroidism (HPT) is one of the most frequentand severe complications of thyroid surgery. It is caused by intraoperative damage, devascularization or accidental removal of the parathyroid glands (PTGs). The incidence of postoperative HPT is directly proportional to surgery extent and surgeon's experience. After 40 years of experience in thyroid surgery, the first author summarizes the already known surgical steps in thyroid surgery and adds some useful practical tips for in situ preservation of PTGs. Our surgical technique focuses on meticulous capsular dissection and preservation of the middle thyroid, Kocher's vein trunk, as well as vein branches that accompany the posterior branch of the superior thyroid artery and inferior thyroid artery trunk. Ligation of all blood vessels should be as close as possible to the thyroid capsule. Identified PTGs should be de-attached from the thyroid capsule on the vascular pedicle without significant dislocation. PTGs preservation during central neck dissection (CND) can be facilitated by using methylene blue dye for sentinel lymph nodes biopsy. PTGs are not colored in blue, unlike central lymph nodes, which facilitates central neck dissection and reduces the possibility of accidental removal of PTGs. After several thousands of preserved PTGs using this original technique, a total prevalence of permanent HPT in the first author's series is less than 0.5%. Following given key points and recommendations to surgical in situ preservation of PTGs, a surgeon can provide good outcome for patients after total thyroidectomy (with or without central neck dissection), regarding HPT as one of the most severe complications of thyroid surgery.