Primary hyperparathyroidism (PHPT) is defined as elevated serum calcium with inappropriately normal or elevated parathyroid hormone. The most common cause is a benign adenoma, more frequent in women. Many cases are asymptomatic due to routine testing. Untreated PHPT can lead to cardiovascular issues, and hypercalcemic crisis is a life-threatening emergency. Surgery (parathyroidectomy) is indicated in symptomatic cases and certain asymptomatic patients. Pre-operative localization using ultrasound and 99mTc-sestaMIBI SPECT is crucial, though these may miss multi-gland disease or ectopic glands. Newer imaging like 4D-CT and choline PET is reserved for complex cases. Surgical approaches range from focused parathyroidectomy to bilateral neck exploration. Surgeons must have a strong understanding of parathyroid anatomy and potential ectopic locations. Adjuncts like IOPTH, frozen section, intra-operative ultrasound, gamma probes, and near-infrared autofluorescence aid in successful surgery.