HomeMinimally Invasive Parathyroid Surgery
Minimally Invasive Parathyroid Surgery
1. Surgery for parathyroid adenoma (primary hyperparathyroidism)
2. Surgery for multiglandular parathyroid disease (parathyroid hyperplasia)
3. Surgery for secondary and tertiary hyperparathyroidism (renal)
4. Reoperative parathyroid surgery
5. Surgery for familial endocrine syndromes: multiple endocrine neoplasia type 1 (MEN1), MEN2A, MEN4, MEN5, and hyperparathyroidism-jaw tumor syndromes
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.
Minimally invasive parathyroid surgery includes video-assisted or endoscopic parathyroidectomy, when the surgeon uses a camera to magnify the view. This technique speeds up the healing process and reduces scar formation. To do a minimally invasive approach, we utilize intraoperative parathyroid hormone (PTH) monitoring to determine the cure after the removal of parathyroid adenoma. About 85 % of the patients with primary hyperparathyroidism (click here to read about primary hyperparathyroidism) will have just one parathyroid adenoma.
Parathyroid Imaging Prior to Surgery
To perform minimally invasive parathyroid surgery, preoperative imaging studies are used to identify and accurately locate the affected parathyroid gland or glands.
Two imaging studies, parathyroid ultrasound and Sestamibi scan, are required for precise preoperative localization of parathyroid lesions in patients with hyperparathyroidism. Our Parathyroid Canter is utilizing a high-sensitivity parathyroid ultrasound machine. Dr Shifrin performs his own parathyroid ultrasounds (US) on all parathyroid patients before surgery (Figure 1). The sensitivity rate is approximately 75-80% for localizing parathyroid adenoma.
The second study is 99mTc-sestamibi fusion single-photon computed tomography (SPECT) and computed tomography (CT) images (SPECT-CT) is the newest and highly sophisticated imaging technology that is designed by fusing 99mTc-sestamibi SPECT and CT slices using fusion software. Dual-phase 99mTc-sestamibi scintigraphy with SPECT-CT enables the identification of a parathyroid adenoma in about two-thirds of patients with primary hyperparathyroidism and allows the surgeon to plan appropriate surgery. A combination of two positive tests — US (Figure 1) and 99mTc-sestamibi scintigraphy (Figure 2) with SPECT-CT — results in 90-95% sensitivity for localizing a parathyroid adenoma and achieving successful minimally invasive surgical exploration.
Figure 1. Parathyroid ultrasound showing right inferior parathyroid adenoma (transverse view)
Figure 2. Sestamibi scan (the same patient as on prior ultrasound, Figure 1)
YOUR SURGERY:
MINIMALLY INVASIVE PARATHYROID SURGERY is performed under high magnification loops (picture above), and video-assisted surgery is performed with a small laparoscopic camera
Anesthesia
The procedure is done under general anesthesia. Some patients would prefer local/regional anesthesia with general sedation, especially during pregnancy. The latter one helps surgeons to use voice monitoring and avoid injury to important nerves that go to your vocal cords
Intraoperative PTH monitoring
Each parathyroid surgery procedure is performed with intraoperative parathyroid hormone (PTH) monitoring. Blood tests for PTH measurements are taken right during the surgery. There are at least four measurements: right before surgery begins (baseline level), during removal of the parathyroid adenoma (T-0 level), and at 5 and 10 minutes after adenoma removal (T-5 and T-10 levels). Intraoperative parathyroid hormone monitoring determines cure if either T5 or T10 levels drop by more than 50% from T-baseline or T-0 levels after removal of the adenoma ("Miami criteria" developed by Dr. Irving). In the picture below, you can see the technician assigned to my surgeries, who performs PTH measurements in the operating room during each parathyroid procedure.
Roche HITACHI PTH machine
Parathyroid hormone (PTH) monitoring. Intraoperative PTH monitoring is performed using the rapid Roche HITACHI PTH machine located in the operating room. Each parathyroid surgery procedure includes intraoperative PTH monitoring, which takes approximately 15 minutes per test.
Parathyroid hormone (PTH) monitoring during parathyroid surgery (tubes)
Intraoperative Frozen Section (biopsy during the surgery)
Each removed parathyroid gland will be sent to a pathologist for intraoperative confirmation of the disease. It is important to have a pathologist examine each parathyroid gland during surgery to ensure it is a parathyroid adenoma or hyperplasia (see picture below showing a hyperplastic parathyroid gland). This takes approximately 20 min for each gland evaluation (see below: magnified microscopic image of parathyroid adenoma)
Hyperplastic parathyroid gland under high magnification microscope
Length of hospital stay
Surgery is performed as an outpatient procedure. The average stay after the surgery is about 3 hours. Most patients do not require an overnight stay.
Pain
Most patients have little or no pain. Most patients have this procedure performed under general anesthesia. If the procedure is performed under general anesthesia, the pain is minimal; if the procedure is performed as a local-regional block with general light sedation, the neck block would last for about 6 - 8 hours. Some patients may feel discomfort or pressure after the surgery. It normally resolves within a couple of days.
Postoperatively, most of the patients have no pain at all. If you do develop mild pain at home, you can take either Tylenol or Motrin.
Drain:
There will be NO drain placement.
Scar and Stitches:
The stitches will be removed the day of the surgery, right before you go home. You will have just a strip of skin glue on the skin. It will peel off on its own in 6-8 days. Because the incision will be small and the stitch will be removed the same day of the procedure, the scar will be much smaller than that of traditional parathyroid surgeries. The incision will be placed in the natural skin crease of your neck, which will help make it less noticeable or even invisible.
However, the scarring tendency is dependent on the individual's skin healing properties. The surgeon will make every effort to achieve the best possible cosmetic result.
Parathyroid adenoma removed during minimally invasive parathyroid surgery
Scar, 2 weeks after the removal of the parathyroid adenoma, showing in the above picture (the same patient)
Click on image to view video “Minimally Invasive Video-Assisted Parathyroidectomy"
COMPLICATIONS:
Voice changes:
Only 0.5% (1 in 200) of patients experience complications related to the damage of the recurrent laryngeal nerve that goes to the vocal cords. When this occurs, the patient will have a hoarse voice or an inability to make high-pitched sounds. In about 1 in 50 operations, patients might experience temporary voice changes, which resolve in 8 to 12 weeks.
Low calcium level:
In about 1 in 100 patients who were operated on and had three and ½ parathyroid glands removed for parathyroid hyperplasia, they may experience permanent low calcium levels. If it happens, patients need to stay on calcium and vitamin D supplementation several times a day for life. Because of the nature of the surgery, all patients will be prescribed calcium supplements for 2-3 weeks. If the patient develops cramps in the hands or legs or tingling in the face muscles, it indicates a low calcium level. In this case, take two calcium pills (1000 mg) immediately and call your doctor. For maximum absorption, Calcium should be supplemented with Magnesium.
Bleeding:
With the current technique, the incidence of bleeding is close to zero.
Wound infection:
With the current technique, the incidence of wound infection is close to zero. You do not need any antibiotics for the surgery, unless you have a condition that requires you to take antibiotics with every procedure.
POSTOPERATIVE CARE:
Incision site:
The skin glue will peel off on its own in about 6-8 days. After that, you can apply selicon-based scar cream, Mederma, or a Vitamin E lotion to the wound about 3-6 times a day. Try not to expose the wound to sunlight for about 1-2 months (especially during summer months), as this can cause skin discoloration in the wound area and make it look different from the surrounding skin.
Physical restrictions:
It is better not to drive for several days if you feel uncomfortable moving your neck. Do not drive if you are taking narcotics such as Percocet or Vicodin. There are no significant physical restrictions, but it is not advisable to perform any neck stretches for 2-3 weeks. Most patients resume their normal physical activities within a day of surgery.
Shower:
You can take a shower the next day. Do not scratch or peel off the skin glue; wipe it with the towel.
Pathology report:
Usually available within 5-7 days after the surgery.
Problem calls:
Please immediately call a doctor if you develop significant neck swelling or shortness of breath shortly after surgery, or if you develop cramps in your hands or legs after the surgery.
Postoperative visit:
2-3 weeks after the surgery: for wound check, pathology report, and PTH and calcium check.
Scars After Parathyroidectomy and Parathyroid Imaging (click here to see more images):
Scar, 2 weeks after a minimally invasive, VIDEO-ASSISTED (with camera) parathyroid surgery, an approach from the left side.
Scar, 2 weeks after a minimally invasive parathyroid surgery for the large parathyroid adenoma (pictured below).
Scar, 2 weeks after a minimally invasive parathyroid surgery
Scar, 6 months after a minimally invasive surgery for the removal of a parathyroid adenoma
Scar, 3 years after a minimally invasive surgery for the removal of a parathyroid adenoma
Scar, 8 months after minimally invasive parathyroid surgery.
A large parathyroid adenoma 6g, 3.3 cm x 2 cm (removed from the patient pictured above).
Parathyroid adenoma.
A large right upper parathyroid adenoma.
Large parathyroid adenoma.
Parathyroid adenoma.
Video-assisted parathyroidectomy, 1.5 cm (1/3 of an inch) scar in 2 weeks after the surgery. The scar after a video-assisted parathyroid surgery is 2 times smaller than with an open minimally invasive surgery (which is about 3 cm (1 and 1/5 inches)
A parathyroid adenoma was removed during a minimally invasive parathyroid surgery.
Large parathyroid adenoma, removed during minimally invasive parathyroid surgery.
Scar, 3 weeks after a minimally invasive parathyroid surgery with four parathyroid gland explorations for a non-localized parathyroid adenoma (left lower parathyroid adenoma was found - picture below)
Left lower parathyroid adenoma from the patient pictured above.
Scar, 2 weeks after a minimally invasive parathyroid surgery with removal of the right lower parathyroid adenoma.
Scar, 2 weeks after parathyroid gland exploration with findings of the right upper 1.5 cm parathyroid adenoma.
Scar, 2 weeks after parathyroid gland exploration with findings of the right lower parathyroid adenoma.
Scar, 4 years after the minimally invasive parathyroidectomy with removal of the right lower parathyroid adenoma.
Scar, 2 weeks after a minimally invasive parathyroidectomy with the removal of the right lower parathyroid adenoma.
Scar, 2 weeks after a minimally invasive parathyroidectomy with the removal of the left upper parathyroid adenoma.
Scar, 10 days after a minimally invasive parathyroidectomy with the removal of the left lower parathyroid adenoma (right after the skin glue came off).
