Primary hyperparathyroidism: targeted, focused exploration with "selective" parathyroidectomy : Minimally invasive open vs. minimally invasive video-assisted vs. endoscopic approach.

Sporadic primary hyperparathyroidism is most commonly caused by a single parathyroid adenoma. Traditionally, bilateral neck exploration with assessment of all four glands was the gold standard, achieving cure rates up to 98%. This approach has largely been replaced by limited exploration (LE), in which a prelocalized hyperfunctioning gland is selectively removed using a small open, video-assisted, or endoscopic approach.Successful LE relies on accurate preoperative localization of single-gland disease. First-line imaging consists of high-resolution ultrasound combined with 99mTc-sestamibi scintigraphy with single-Photon Emission Computerized Tomograph (SPECT/CT). When results are negative or discordant, 18F-choline PET/CT is recommended, significantly improving localization and enabling targeted surgery..Because multiglandular disease cannot be definitively excluded preoperatively, intraoperative parathyroid hormone (IOPTH) monitoring has become an important adjunct. IOPTH confirms complete excision of hyperfunctioning tissue and aids detection of additional abnormal glands. Several interpretive criteria exist, including Miami, Vienna, Halle, and Rome, with Miami and Vienna most commonly used. Although routine IOPTH use in concordantly localized single-gland disease remains debated, evidence suggests it reduces persistent disease and reoperation rates, particularly when imaging is inconclusive.Endoscopic, extracervical, and robotic approaches offer superior cosmetic outcomes but involve greater dissection, higher costs, and increased technical demands, limiting widespread use. Overall, advances in imaging and intraoperative adjuncts have enabled minimally invasive parathyroidectomy to replace bilateral exploration while maintaining excellent long-term outcomes.