Though the majority of controversy concerning ambulatory endocrine surgery involves thyroidectomy, there are several notable issues related to parathyroid surgery. Analogous to thyroidectomy, the classic approach to parathyroidectomy involved a low-collar incision, large subplatysmal flaps, and mandatory bilateral exploration, historically requiring suction drain placement and inpatient observation. With the advent of improved parathyroid adenoma localization (sestamibi localization and ultrasound imaging) and with the use of intraoperative PTH assays, limited unilateral dissections have become standard. With less dissection, surgery for well-localized adenomas is extremely well tolerated by the vast majority of patients. Virtually all healthy patients are candidates for outpatient surgery. Localized excisions are reported to be very safe even in morbidly obese and elderly patients.

Parathyroid operations that require four-gland exploration raise the risk of postoperative hypoparathyroidism and are slightly more uncomfortable than localized procedures, though they are still tolerated quite well. The majority of patients are eligible for outpatient surgery which is performed more liberally than for patients undergoing total thyroidectomy. This is because the risk of hypocalcemia (with solitary adenoma excision), hematoma, and vocal cord paralysis is significantly less following parathyroid surgery compared to total thyroidectomy.

There are several unique risks to parathyroid surgery, however. In addition to hemodilution, and parathyroid devascularization, postoperative hypocalcemia may uniquely result from hungry bone syndrome for patients with long-standing or severe hyperparathyroidism. The risk of post-parathyroidectomy hypocalcemia is directly proportional to preoperative hypercalcemia and is increased in patients with bone density scores ≤ −3 and when all four glands have been manipulated. Hypocalcemia can be quite significant, not infrequently reaching symptomatic levels, yet because calcium levels are high preoperatively, it may take 48–72 h for serum levels to reach a nadir. Therefore, overnight admission is not adequate to completely trend calcium levels. In general, we prefer outpatient management in patients with primary hyperparathyroidism, even in patients at increased risk of developing hypocalcemia. Calcium levels are drawn 48 h following surgery for patients at risk for hungry bone syndrome or when there is concern for significant devascularization. A PACU-drawn PTH level may also be helpful in this setting, though we have only found it to be predictive of hypocalcemia if PTH levels are very low or undetectable. This is because serum calcium levels typically remain high in the immediate postoperative period appropriately suppressing PTH levels.

Patients with renal failure and secondary or tertiary hyperparathyroidism also offer a unique challenge following surgery. These patients typically become hypocalcemic quickly and dramatically, following 3 ½ gland parathyroidectomy, typically requiring aggressive oral and intravenous calcium replacement. Therefore, patients with secondary and tertiary hyperparathyroidism should not undergo outpatient surgery and these conditions should generally be considered contraindications to an ambulatory approach.

Patients should meet the discharge criteria listed in Table 4.2 prior to same-day discharge. Patients must have received proper education and a discussion about risks of complications must be addressed. Education should be reinforced with written instructions provided by the surgeon or discharge nurse. Nurses must be trained to comfortably assess the neck and respiratory status of the patient if the surgeon is not present at the time of discharge. Adequate family support and adequate functional status should be assessed. The patient should receive either routine calcium therapy or supplementation based on a selective PTH protocol. Anesthesiology staff should clear the patient for discharge and assess for recalcitrant nausea and vomiting. Coordination of these steps should not be underestimated, and initially will take significant communication with anesthesiology and nursing staff. Ultimately, multidisciplinary care is paramount to successful outpatient endocrine surgery.