Firstly establish if this is persistent or recurrent disease:

These are amongst the most challenging cases for the endocrine surgeon. Therefore it is important to confirm that the patient has symptoms that justify further surgery or evidence of secondary end organ damage from hyperparathyroidism by way of bone disease or renal stones.

Reoperation should only be considered if the patient is symptomatic or there is objective evidence of progressive disease, bone or renal, which justifies the risks and uncertainties of further surgery.

The operating surgeon should consider whether this could be a patient with a predisposition to multiglandular disease such as MEN1 or MEN2. A family history of endocrine syndromes or other components of these syndromes such as pituitary, adrenal, or pancreatic tumors should be sought because recurrent hyperparathyroidism raises the real possibility of an underlying predisposition syndrome.