Secondary hyperparathyroidism is the compensatory increase in parathyroid hormone levels as a result of disorder in calcium homeostasis, whilst tertiary hyperparathyroidism refers to the autonomous function of the parathyroid glands with excessive parathyroid hormone secretion after long-standing secondary hyperparathyroidism. Both disorders are often associated with comorbid conditions such as kidney failure. Long-term impacts of secondary and tertiary hyperparathyroidism include visceral and vascular calcifications as well as bone damage. The primary treatment of secondary and tertiary hyperparathyroidism is medical therapy, which aims to maintain calcium and phosphorus levels in the normal range. When medical therapy is not successful, surgery may be indicated. The surgical approach generally involves identification of all four parathyroid glands and removal of at least three glands. The decision to perform a total (with or without autotransplantation) versus subtotal parathyroidectomy is nuanced and the subject of continued debate. Several intraoperative adjuncts are available to the surgeon to assist in performing these complex procedures. This chapter details the surgical management of secondary and tertiary hyperparathyroidism.