Minimally Invasive Parathyroid Surgery
Minimally Invasive Parathyroid Surgery
Minimally invasive parathyroid surgery is the removal of one or several parathyroid adenomas through a small neck incision. The incision is placed in the natural skin crease.
Parathyroidectomy is the standard therapy for patients with primary hyperparathyroidism. Imaging, including technetium Tc 99m-sestamibi single-photon emission computed tomography and parathyroid ultrasonography, have improved preoperative localization, while intraoperative parathyroid hormone measurement provides a rapid test to confirm operative success. These adjuncts have enabled surgeons to perform an operation that is both safe and minimally invasive. An experienced parathyroid surgeon should one who perform the operation after a comprehensive preoperative workup, consisting of biochemical and localizing imaging studies.
Parathyroidectomy not only provides a biochemical cure, but various studies have demonstrated improvements in bone mineral density, cognitive function, and cardiovascular disease and a decrease in premature death rates, fracture rate, and kidney stone formation. Patients with symptomatic primary hyperparathyroidism should undergo parathyroidectomy. Surgical treatment guidelines for asymptomatic patients were published by the National Institute of Health Consensus Conferences in 1990, 2002 and most recently by the Third International Workshop in 2009. Asymptomatic patients younger than 50 years with a serum calcium concentration 1 mg/dL above the upper limit of normal or a bone mineral density T score of 2.5 or lower at any site should be referred for surgery.
Under general or local anesthesia, a midline 2- to 4-cm transverse incision is made within a skin crease. A very rare a lateral, on the side where preoperative localizing studies have identified, the hyperfunctioning parathyroid gland. The length of the incision often depends on patient body habitus and adenoma size.
Minimally invasive parathyroid surgery is the removal of one or several parathyroid glands (adenomas) through a small transverse mid neck incision. The incision is placed in the natural skin crease. To remove locolized parathyroid adenoma surgery takes about 15 min. Minimally invasive parathyroid surgery includes video-assisted or endoscopic parathyroidectomy, when surgeon uses camera to magnify the view. This technique makes the healing process faster and with minimum scar formation. In order to perform minimally invasive approach preoperative studies to localize adenoma must be used. Those studies include preoperative neck parathyroid ultrasound and Sestamibi (parathyroid) scan. I am also utilizing intraoperative parathyroid hormone (PTH) monitoring to determine the cure after the removal of parathyroid adenoma immediatly during surgery. Majority of the patients have this procedure performed under general anesthasia, but local anesthesia with neck block (regional anesthesia) with general sedation (like it is done with colonoscopy procedures) also could be an option. About 85 % of the patients with primary hyperparathyroidism will have just one parathyroid adenoma. I do not place or use any drains during the surgery and after the surgery. Skin is closed either without any sutures by using a skin glue, and on rare occasions, with subcuticular sutures (under the skin, dissolvable). Parathyroid surgery is usually the same day surgery. Patient stays in the hospital after the surgery for 3 hours of observation.
Intra-operative PTH monitoring
Minimally Invasive Parathyroid Surgery, JSUMC 2016
Bilezikian JP, Khan AA, Potts JT Jr; Third International Workshop on the Management of Asymptomatic Primary Hyperthyroidism. J Clin Endocrinol Metab. 2009 Feb;94(2):335-9.
The diagnosis and management of asymptomatic primary hyperparathyroidism revisited.
Khan AA, Bilezikian JP, Potts JT Jr; Guest Editors for the Third International Workshop on Asymptomatic Primary Hyperparathyroidism.
Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. Silverberg SJ, Lewiecki EM, Mosekilde L, Peacock M, Rubin MR. J Clin Endocrinol Metab. 2009 Feb;94(2):351-65.
Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. Eastell R, Arnold A, Brandi ML, Brown EM, D'Amour P, Hanley DA, Rao DS, Rubin MR, Goltzman D, Silverberg SJ, Marx SJ, Peacock M, Mosekilde L, Bouillon R, Lewiecki EM. J Clin Endocrinol Metab. 2009 Feb;94(2):340-50.
A. Harari, J. Allendorf, A. Shifrin, M. DiGorgi, and W. Inabnet, “Negative preoperative localization leads to greater resource utilization in the era of minimally invasive parathyroidectomy”. American Journal of Surgery. 2009 Jun;197(6): 769-73.
Neuroendocrine Thymic Carcinoma Metastatic to the Parathyroid Gland that was Reimplanted into the Forearm in Patient with Multiple Endocrine Neoplasia Type 1 Syndrome: A Challenging Management Dilemma. Shifrin A , Livolsi V, Zheng M, Lann D, Fomin S, Naylor E, Mencel P, Fay A, Erler B, Matulewicz T. Endocr Pract. 2013 Sep 6:1-14.
M. Augustine, P. Bravo, M. Zeiger. "Surgical Treatment of Primary Hyperparathyroidism". Endocr Pract. 2011;17 [Suppl 1]:75-82