A patient undergoes bilateral neck exploration for primary hyperparathyroidism. All four glands appear hypercellular and enlarged. Pathology confirms four-gland hyperplasia. The correct surgical management according to current guidelines is:

• A Total parathyroidectomy without autotransplantation
• B Removal of the two largest glands only
• C Medical management with cinacalcet; surgery deferred
• D Subtotal parathyroidectomy (3.5 glands removed) or total parathyroidectomy with autotransplantation ✓

Explanation

For multigland disease/four-gland hyperplasia in primary hyperparathyroidism, the standard surgical approach is either subtotal parathyroidectomy (removing 3.5 glands, leaving a well-vascularized remnant equivalent to one normal gland) or total parathyroidectomy with immediate autotransplantation of parathyroid tissue into the brachioradialis muscle or sternocleidomastoid. Both approaches achieve cure rates >90% and allow for easier re-exploration if recurrence occurs (forearm vs. neck). Removal of only two glands risks persistent hyperparathyroidism.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.