Minimally invasive video-assisted parathyroidectomy (MIVAP): bilateral exploration

作者群

摘要

This is an interesting video of a minimally invasive video-assisted parathyroidectomy (MIVAP) with bilateral neck exploration in which three dimensional reconstruction using the IRCAD technique is very helpful.

關鍵字

Minimally invasive, video-assisted, parathyroidectomy, MIVAP, bilateral exploration

媒體類型

期間

09'47''

刊物

2010-11

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3136.htm

Minimally invasive video-assisted parathyroidectomy (MIVAP): bilateral exploration

1. Introduction 00'18''

This 65-year-old patient presents with primary hyperparathyroidism. It has been found due to the presence of a 2.70mmol hypercalcemia in a routine blood test. The hyperparathyroidism was evidenced by an elevated parathyroid hormone level (115 pg/ml). Medical imaging was performed prior to the intervention. It consisted of an injected cervico-mediastinal CT-scan and a 3D reconstruction made by the IRCAD. The reconstruction showed two potential adenomas: a left superior parathyroid adenoma and a right inferior parathyroid adenoma placed in the thyrothymic ligament. The superimposition of the images, performed by the IRCAD’s team, is carried out at the beginning of the procedure. The clavicles and the thyroid cartilage allow for a size adaptation between the virtual images and the real ones.

2. Incision 01'28''

A 2.5cm incision is made 2cm above the sternal notch. The subcutaneous tissue is dissected. The intervention is pursued towards the lateral portion, anterior to the longitudinal muscles. As soon as entrance is made, one may be amazed by the image of the inferior pole. The dissection of the neck is performed in order to find the different structures and landmarks to allow for a successful exploration of the parathyroid areas.

3. Carotid artery identification 02'16''

The lateral region of the neck is explored. The carotid artery is identified. The space between thyroid and carotid is then slowly dissected in order to avoid bleeding. A middle thyroid vein is clipped and divided.

4. Identification of inferior thyroid artery and recurrent nerve 02'52''

Dissection allows to identify the inferior thyroid artery, which will be followed. The recurrent nerve can be visualized. It will be dissected over 1cm. From now on, dissection will be pursued on the superior and lateral portion, above the inferior thyroid artery, in contact to its most cranial branch.

5. Esophagus identification 03'33''

The esophagus is identified. A dome can be found in the pre-esophageal fat, in contact to the thyroid. The objective of the dissection is to isolate this dome. Once again, dissection is performed in a slow and progressive fashion in order to avoid vascular damage. The anterior portion of the esophagus and a superior parathyroid gland can be well visualized. The latter does not have the same size as the one seen during virtual reconstruction. It will be left in place for the moment.

6. Adenoma identification 04'48''

The procedure is further carried out at the inferior portion of the thyroid. As soon as the neck is opened and dissection is started, a parathyroid adenoma is found. It is seated, literally, just above the lower portion of the thyroid gland. This adenoma is dissected. Its pedicle will be isolated once all the adhesions attaching the gland to the inferior aspect of the thyroid gland have been taken down. The pedicle will then be clipped and divided. A few more adhesions are divided once again by means of the hook. It is a typical parathyroid adenoma. Its dimensions are 12 by 11 by 6mm. Its color is deep red. Once divided, one can see that it is a typical adenoma. Its adenomatous nature will be confirmed by the pathological examination and frozen section. Extra attention is paid to the reconstruction. A shape anomaly on the lower portion of the thyroid lobe, measuring 11mm in diameter, is then found. It stands for the parathyroid adenoma, which was difficult to identify because it was almost perfectly attached to the thyroid parenchyma.

7. Right exploration 06'42''

Exploration of the right portion of the neck is then undertaken in order to rule out the presence of a lower right parathyroid adenoma. The lateral region of the neck is opened.

8. Carotid artery identification 07'06''

Here again, attempts are made to identify the carotid artery. A middle thyroid vein is found here. It will be divided over two clips. From then on, the space between thyroid and carotid will be completely opened.

9. Recurrent nerve identification 07'29''

The first landmark to be found is the recurrent nerve, which is relatively close to the trachea here. Once the recurrent nerve has been found, the inferior thyroid artery is dissected. The dissection is then carried on anterior to the junction between artery and nerve to search for the inferior parathyroid gland. The trachea is rapidly found and a normal parathyroid gland is searched for just anterior to the nerve —normal in its shape, its consistency, its color, and in its position. The dissection is then further continued laterally above the inferior thyroid artery in order to find the right superior parathyroid gland at the most cranial branch of the inferior thyroid artery. This right superior parathyroid gland is dissected and freed from its capsule in order to fully appreciate its color, size, and consistency. It will be left in place. Here successively the superior parathyroid gland, the recurrent nerve, the inferior thyroid artery, and, anteriorly, the inferior parathyroid gland are clearly visible. The intervention is carried on to the other side where there was a superior parathyroid gland too globular to be normal. Hence, its resection is decided upon at the same time. Since it has been perfectly dissected, it will be resected. Its dimensions are 6 by 6 by 6mm. Visualization of the neck demonstrates the absence of bleeding. The scar is closed using an intradermal running suture.

使用者名稱
密碼
	記得我 (必須啟動Cookies設定)