A confirmed diagnosis and proper indication are not a sufficient basis to proceed with reoperative parathyroidectomy. In fact, these two elements are the minimum threshold that must be established before surgery can even be considered.

When considering any medical treatment, the potential risks and benefits of said treatment modality need to be carefully weighed. With the excellent success rates and low incidence of complications in primary parathyroidectomy, making this assessment is often straightforward. However, as noted earlier, the likelihood of cure may be lower and the risk of complications possibly greater in reoperative parathyroidectomy. Therefore, for remedial surgery to be sensible, the strength of the indication and the related potential benefits should be greater in order to outweigh the increased risks.

Multiple factors impact the prospect for success without complication in reoperative parathyroidectomy. When considering surgery, the first step is to try to understand the cause of the persistent or recurrent disease. If it is the result of surgical failure, the reason for failure may be unclear. Anatomic, biologic, and/or surgical variables can be the basis for not achieving cure during initial surgery. In order to evaluate these potential variables, all prior notes, radiology examinations, operative reports, and pathology and lab results should be carefully reviewed. A major determinant in the success rate of reoperation is the number of glands responsible for the hyperparathyroidism. A single adenoma is more likely than multiglandular involvement to be successfully identified and excised during remedial surgery. Possible insight into the number of glands involved can be offered by lab results, imaging studies, family history, and operative findings, especially related to the extent of exploration. In regard to localization studies, simply examining radiology reports is never optimal when planning parathyroid surgery. However, in the context of remedial surgery, directly studying the images of these tests is absolutely essential. It is also paramount to understand which areas were dissected and examined and which may not have been; which parathyroid glands were removed, partially excised, or biopsied; and which gland(s) or remnant(s) were marked with clips or suture. It is wise to not accept as fact a surgeon’s report of identifying a parathyroid gland(s) during surgery based on visualization alone.

Patient-specific elements then need to be assessed. Has the patient had prior thyroid surgery, anterior cervical disk fusion, or other neck operations? Is the patient’s body habitus a potential obstacle because of difficulties it may cause with exposure? Does a high body mass index mean more extensive cervical fat and soft tissue, possibly a harbinger of a more challenging exploration ? Are there signs of thyroiditis, which can lead to additional fibrosis, as well as extensive adenopathy (which may mimic pathologic parathyroid glands)?

When calculating the risk-benefit and success profile of possible reoperation, other patient factors that need consideration are the patient’s age, occupation, lifestyle, and ability to tolerate potential complications and if they have had complications from the initial surgery that may make reoperative surgery even more dangerous. For example, based on career and lifestyle requirements, is a recurrent nerve injury going to be a simple inconvenience or a life-changing impediment? If a patient becomes temporarily or permanently hypocalcemic after surgery, are they going to be able to reliably take calcium and vitamin D supplements? These details should all be considered in potential reoperative patients.