OT notes · General Surgery

Parathyroidectomy

Usual anaesthesia
General anaesthesia (local with sedation possible for focused excision)
Position
Supine, neck extended on a head ring with a bag or roll under the shoulders, head-up tilt
Setting
elective

Operative note template for parathyroidectomy (focused excision of an adenoma or bilateral four-gland exploration), with a filled example for focused excision of a right inferior parathyroid adenoma with intra-operative PTH monitoring.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • low calcium after surgery (tingling, cramps), temporary or permanent
  • recurrent laryngeal nerve injury with hoarse voice, both sides can cause airway obstruction
  • neck haematoma, which can block the airway
  • persistent or recurrent hyperparathyroidism, needing re-operation
  • conversion to bilateral exploration
  • removal of part of the thyroid or thymus to find a missing gland
  • forearm incision if tissue is autotransplanted

Pre-operative details for this operation

  1. DiagnosisPrimary hyperparathyroidismSecondary hyperparathyroidism (renal)Tertiary hyperparathyroidismFamilial / MENserum calcium, intact PTH, phosphate, creatinine, 25-OH vitamin D, ALP
  2. Indicationstones, bone disease (T score), calcium level, age, symptoms
  3. Localisationultrasound and sestamibi results: side and position, concordant or not
  4. Operation plannedFocused excisionBilateral four-gland explorationSubtotal parathyroidectomyTotal parathyroidectomy with forearm autotransplantreason (e.g. discordant or no localisation, MEN, secondary HPT need bilateral exploration)
  5. Vocal cord checkBoth cords mobile on laryngoscopyNot done (no voice change, no prior neck surgery)
  6. Hypercalcaemia controlhydration, drugs given if calcium very high
  7. Intra-operative PTH and frozen sectionIOPTH availableFrozen section availableNeither

Anaesthesia and position

  1. AnaesthesiaGeneralLocal with sedation
  2. PositionNeck extended, head ring, shoulder roll, reverse Trendelenburg
  3. Nerve monitoringUsedNot used
  4. Baseline PTH samplesite (peripheral vein / IJV) and time, before incision

Operative findings

  1. Abnormal gland(s)which gland, exact position, size, colour, consistency
  2. Other glands seenfor each of the four: seen or not, normal or enlarged, biopsied or not
  3. Recurrent laryngeal nerveIdentified and preservedNot exposed (focused)side(s)
  4. Thyroidnormal / nodules
  5. IOPTH valuesbaseline, pre-excision, 10 min after excision (and 20 min if needed), percentage fall

Procedure (steps)

  1. IncisionTransverse skin crease about 1 cm below cricoid (2.5 to 3 cm, focused)Collar incision (bilateral exploration)Along anterior border of sternomastoid (lateral approach)length
  2. Subplatysmal flaps and strap musclesflaps to thyroid notch and suprasternal notch, straps divided in the midline raphe and retracted
  3. Middle thyroid vein ligated, thyroid lobe rotated mediallyside(s)
  4. Recurrent laryngeal nerve identified
  5. Glands searchedsuperior glands dorsal to the nerve near the upper pole, inferior glands anterior to the nerve near lower pole and thyrothymic ligament, ectopic sites searched if missing
  6. Abnormal gland excisedfreed by sharp dissection, vascular pedicle tied (e.g. silk 3-0) or clipped
  7. Multigland diseaseNot applicableSubtotal: 40 to 50 mg remnant of most normal gland left, clip on itTotal with autotransplant into brachioradialisnumber of forearm pockets, suture marking them
  8. Cervical thymectomyNot doneDonereason (hyperplasia, missing inferior gland)
  9. Confirmation of cureIOPTH fall of 50% or moreFrozen section confirmed parathyroidOther
  10. HaemostasisValsalva if asked of anaesthetist

Closure, drains and dressing

  1. Strap musclesabsorbable suture, small gap left at the lower end or not
  2. Platysmaabsorbable suture
  3. SkinSubcuticular absorbableSkin clips
  4. DrainNoneSuction drain (reason)
  5. Voice at extubationnormal / hoarse

Specimens and implants

  1. Parathyroid gland(s) for HPElabel each: side, superior or inferior, size, weight if taken
  2. Frozen sectionwhich tissue, result
  3. Thymus / thyroid tissueNot removedSent for HPE

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neck swelling and breathingcheck hourly, inform at once if the neck swells or breathing becomes difficult
  2. Symptoms of low calciumtingling around mouth or fingers, cramps: inform doctor
  3. Serum calciumtiming as per unit protocol, at first follow-up and at 6 months
  4. Oral calciumif symptoms: calcium 500 to 1000 mg three times a day
  5. Voicenote hoarseness, laryngoscopy if present
  6. Dietorally when fully awake
  7. Analgesiadrug, dose, frequency
  8. Dressing and follow-updressing on 48 hours, review at 2 weeks with HPE

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. K.J., 48 years, recurrent renal stones, serum calcium 11.6 mg/dl, intact PTH 184 pg/ml, 25-OH vitamin D normal, ultrasound and sestamibi both show a right inferior parathyroid adenoma.

Case details

Date: 09/11/2026. Elective. OT 2.

In OT 09:00. Induction 09:10. Incision 09:30. Adenoma out 10:05. Closure completed 10:40.

Surgeon: Dr C. (Consultant, General Surgery). Assistant: Dr A. (3rd-year resident), who opened, retracted and closed. Dr B. (1st-year resident) observing.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic primary hyperparathyroidism (renal stones). Concordant localisation: right inferior gland on ultrasound (1.4 cm hypoechoic nodule below right lower pole) and on sestamibi.

No family history. Not MEN. Voice normal, no prior neck surgery, laryngoscopy showed both cords mobile.

Consent: focused right parathyroidectomy, possible bilateral exploration. Risks of low calcium, voice change, haematoma and failure to cure explained in English and Hindi.

WHO checklist done. No antibiotic prophylaxis (clean neck operation). IOPTH arranged with the laboratory.

Anaesthesia and position

General anaesthesia with endotracheal intubation. Neck extended on a head ring with a sandbag under the shoulders, head-up tilt. Parts painted with povidone-iodine and draped.

Baseline PTH drawn from antecubital cannula at 09:25: 190 pg/ml.

Procedure

3 cm transverse skin crease incision 1 cm below the cricoid. Subplatysmal flaps raised. Strap muscles separated in the midline and retracted to the right.

Right middle thyroid vein ligated and divided. Right lobe rotated medially. Right recurrent laryngeal nerve identified in the tracheo-oesophageal groove and preserved.

Findings: right inferior parathyroid adenoma 1.5 x 1.0 cm, reddish-brown, firm, below the lower pole, anterior to the nerve. Right superior gland seen, normal size and colour, not disturbed. Thyroid normal.

Adenoma freed by sharp dissection. PTH drawn just before excision at 10:02: 260 pg/ml. Vascular pedicle clamped and tied with silk 3-0. Adenoma removed intact at 10:05.

PTH at 10 minutes after excision (10:15): 48 pg/ml, an 82% fall from the highest pre-excision value. Left side not explored.

Haemostasis checked. No bleeding.

Closure

Strap muscles approximated in the midline with interrupted polyglactin 910 (Vicryl) 3-0. Platysma with Vicryl 3-0. Skin with subcuticular poliglecaprone (Monocryl) 4-0. Steri-strips. No drain.

Voice normal after extubation.

Specimens and implants

Right inferior parathyroid gland, 1.5 x 1.0 cm, sent for HPE in formalin. No implants.

End of procedure

Estimated blood loss 20 ml.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery awake and stable. Pulse 78/min, BP 128/80 mmHg.

Post-op orders

Watch neck for swelling and breathing hourly for 6 hours. Inform at once if the neck swells or breathing is difficult.

Inform if tingling around the mouth or in the fingers, or cramps.

Oral fluids when awake, normal diet in the evening.

Tab paracetamol 500 mg, 2 tablets 6-hourly when needed, not more than 8 tablets in 24 hours.

If symptoms of low calcium: oral calcium 500 mg three times a day, and check serum calcium.

Serum calcium at the 2-week visit with HPE report, and at 6 months.

Signature

Dr A., JR-3, General Surgery, for Dr C. Reg. no. ________. 09/11/2026, 10:55.

Must document for this operation

  • Localisation results and why focused or bilateral exploration was chosen. If the patient is not cured, the choice of operation is the first thing reviewed.
  • Each parathyroid gland seen: position, size, appearance, and what was done to it. A re-operation in a scarred neck depends on knowing which glands were seen and which were left.
  • Recurrent laryngeal nerve identified and preserved, and voice at extubation. A later voice complaint is judged against this record.
  • IOPTH values with times, or frozen section result. These show the operation was stopped for a measured reason, not by guess.
  • Site of any remnant or forearm autograft and how it was marked. In recurrent disease, the next surgeon needs to find this tissue.
  • Specimen labelled by gland. The pathologist and the next surgeon need to know which gland each specimen came from.

Common mistakes in these notes

  • Writing 'adenoma excised' without saying which gland or where it was.
  • Not recording the other glands seen or not seen.
  • Giving intra-operative parathyroid hormone (IOPTH) values without the times drawn.
  • No post-op instruction for symptoms of low calcium.
  • Not recording voice at extubation.

Indian practice and paperwork

  • Name every anaesthetist in the note. A hospital was held negligent where the operation note did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The operative note must be written before the patient leaves recovery, and post-op care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • Parathyroid tissue not sent for HPE is human anatomical waste for the yellow bag. Discarded formalin is chemical waste, yellow (f). (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Scott-Conner CEH, Dawson DL. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Wolters Kluwer; 2014, Ch 7, Parathyroidectomy (Walsh JE, Lal G), pp. 46-55.
  • Mulholland MW (editor-in-chief), Albo D, Dalman RL, Hawn MT, Hughes SJ, Sabel MS, eds. Operative Techniques in Surgery. Wolters Kluwer; 2015, Ch 41, Open Neck Exploration for Primary Hyperparathyroidism, pp. 1700-1710.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. Table 2: head and neck, clean: no prophylaxis. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • Operative Techniques in Surgery, Ch 41, pdf p. 1743: oral calcium 500 to 1000 mg three times daily for symptoms of hypocalcaemia; serum calcium at first visit and at 6 months.
  • NHS. How and when to take paracetamol for adults. 500 mg tablets: 1 or 2 tablets per dose, at least 4 hours apart, not more than 8 tablets in 24 hours. www.nhs.uk/medicines/paracetamol-for-adults/how-and-when-to-take-paracetamol-for-adults/

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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