1. Case History 70/F, Known Diabetic, Hypertensive, Anemic (Hb7.6gms%), IHD, TMT Positive, Electrolyte imbalance, not able to walk or stand past 1 month Presented with Hypercalcemic crisis (Coma- 2 months back), Persistent nausea & Vomiting Evaluated

3. Very High Calcium & PTH

4. Biochemistry

5. Hypercalcemic crisis managed medically

7. Concordant USG & Sestamibi Findings

8. Sestamibi Scan

9. USG: Showed a Single Right adenoma

11. Anaesthetist view

12. Cardiologist Opinion: Very High surgical risk for Cardiac events Transfused 1 pint of Packed RBCS the day before Surgery

13. Positioning

14. Plane between straps and sternocleidomastoid(SCM) muscle right side SCM Straps

15. Parathyroid visulaisation SCM Parathyroid tumor

16. Visulalisation of both Parathyroid tumors Inferior Superior

17. Thyroid Superior Inferior Double Parathyroid adenomas

18. Thyroid Tumor bed after removal of both Parathyroid tumors, Wound Closed without a drain

19. Surgical Specimen

20. Closer view of the Double adenomas Superior: 3.2x2.7x1.1cm Weight 8.2 gms Inferior: 4.2x 3.1x2.6cm Weight 14.6 gms

21. Post op Serum CalciumSerum PTH Preop 20.1, 19.0 15.6, 15.2, 12.4, 11.4 ( after 3 doses of Bisphophonates) 3864.6 pg/ml Post op9.1 304 pg/ml (1 hour postop) Postop Day 27.2 Postop Day 38.1 (with calcium & Vit D Supplements)- discharged Patient did not develop symptomatic hypocalcemia, Voice normal, Wound healthy discharged with Oral Calcium & vitamin D supplements