Natural Orifice Approach to Parathyroid Surgery: An Anesthesiologist’s Challenge

Endocrine surgeries pose unique challenges to the anesthesiologists, so is the case in primary hyperparathyroidism due to hypercalcemia. A 29-year-old male, operated case of intertrochanteric femur neck fracture following trivial fall, had history of frequent muscle cramps and fatiguability post operatively and swelling in right side of front of neck. On investigating, his thyroid function tests were normal, elevated serum calcium, alkaline phosphatase and parathormone, and decreased phosphate. After ultrasound of neck and abdomen, the patient was diagnosed with primary hyperparathyroidism and posted for peroral endoscopic parathyroidectomy under general anesthesia. Induction was done with propofol and succinylcholine video-direct laryngoscopy-guided nasal intubation was done to avoid the pathological fracture of cervical spine; maintained on isoflurane, fentanyl and titrated doses of vecuronium; extubated smoothly and shifted to intensive care unit. Thorough perioperative monitoring of electrolytes including calcium was done. Adequate preoperative assessment, preparation, monitoring the signs and symptoms of hypo/hypercalcemia, and maintaining normocalcemia during perioperative period determines the success of anesthetic management.