Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism

In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT). Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.

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Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism

Authors

M Vix, L Soler, J Marescaux

Abstract

In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT).
Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.

Classification

basic techniques

Keywords

Minimally invasive video-assisted parathyroidectomy, primary hyperparathyroidism

Media type

Surgical video

Duration

04'35''

Publication

2009-03

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E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2567.htm

Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism

1. Clinical case presentation 00'07''

This is the case of a 65-year-old female patient presenting with a primary hyperparathyroidism that was found during a routine examination for arthritis. The patient had hypercalcemia (115 mg/L); her PTH levels were at 105 pg/mL, and hypophosphoremia was also observed. Faced with such a blatant clinical sketch of primary hyperparathyroidism, several imaging studies have been performed. A neck ultrasonography suspected a right superior parathyroid adenoma. A three-dimensional reconstruction of CT-scan images also showed a suspicion of a right superior parathyroid adenoma in an inter-crico-thyroid position. The remainder of the CT-scan examination did not reveal any other significant abnormalities.

2. Start of the minimally invasive cervical approach 01'08''

A minimally invasive cervical approach is decided upon. A 2.5 cm cervicotomy is therefore carried out 2cm above the sternal notch. The space between the vascular axis and the right thyroid lobe is freed in order to progressively ensure a deeper access into it. The inferior thyroid artery is searched for by moving along the lateral and posterior aspect of the thyroid gland. The posterior bone plane is then rapidly reached. Based on the CT-scan image that revealed a suspicion of an adenoma situated in an inter-crico-tracheal position, dissection is continued towards the superior pole on the lateral and posterior aspect of the thyroid gland. The superior pole is widely dissected and the superior thyroid vessels are reached.

3. Parathyroid adenoma identification 02'15''

At this moment, we have the feeling that there is a parathyroid adenoma, which is felt and will have to be dissected. Palpation helps to find a specific mobility of the tissues lying underneath this adipose fold. Dissection is then extended towards the superior and medial part while keeping contact with the adenoma.

4. Opening the adenoma capsule 02'40''

The opening of the capsule helps to find it more precisely. A line of adipose tissue lies inferiorly.

5. Dissecting the adenoma\'s superior pole 02'55''

Then the superior pole of the adenoma is dissected with the aid of both the hook and the aspirating spatula.

6. Vascular network identification 03'36''

The vascularity of the adenoma may be seen on the posterior aspect of the adenoma. Its vascular supply originates partly from the superior thyroid artery.

7. Vascular network clipping and division 04'01''

We have freed the entire vascular network, which will be clipped.

8. Adenoma resection and extraction 04'07''

The adenoma is resected, then extracted. Its dimensions are as follows: 20 by 10 by 5mm. The pathological exam confirms a parathyroid adenoma. The intraoperative PTH assay shows a progressive and rapid decrease in PTH levels ranging from 150 pg/mL in the preoperative period T0 to 24 pg/mL at T15 minutes.