Controversy surrounds criteria for medical versus surgical treatment in the management of asymptomatic or minimally symptomatic hyperparathyroidism. Evidence suggests that parathyroidectomy is associated with increases in bone mass and symptomatic improvement of patients; moreover, parathyroidectomy by experienced surgeons is rarely associated with complications. Intraoperative parathyroid hormone (PTH) measurement, improved preoperative and intraoperative imaging and outpatient parathyroidectomy are important emerging surgical technologies.