Parathyroidectomy is performed most commonly in patients with primary hyperparathyroidism and those who are dialysis dependent and have symptomatic secondary hyperparathyroidism. In rare patients who have hypercalcemia on dialysis or after renal transplantation (tertiary hyperparathyroidism), operation is also indicated. A physical examination, chest radiograph, intravenous pyelogram (on unusual occasions), and modern parathormone assay distinguish between primary hyperparathyroidism and the hypercalcemia of sarcoidosis, metastases, or a paraneoplastic syndrome. A 24-hour urinary calcium test is occasionally indicated to rule out familial hypocalciuric hypercalcemia. Currently, virtually all preoperative patients undergo cervical ultrasonography or radionuclide scanning after the intravenous injection of 99mTechnetium-labeled sestamibi in order to allow for shortened operations through limited incisions.

Preoperative therapy to lower extraordinarily elevated serum calcium levels in patients with parathyroid comas or suspected carcinomas should include saline infusions, furosemide, and occasionally calcitonin. Parathyroidectomy is usually performed under general anesthesia through a low collar incision, although local anesthesia is appropriate for elderly and high-risk patients as well as those undergoing minimally radio-guided parathyroidectomy or “no frills” image-guided exploration.

There has been a rapid evolution in parathyroid surgery over the past 5–7 years. At present, there are at least five different operative approaches being utilized. Conventional parathyroid exploration performed through the standard low collar incision, in which the size of all four glands is assessed, is now accompanied by measurement of intraoperative intact parathyroid hormone levels.