Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique

This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field. A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.

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Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique

Authors

F Costantino, M Vix, J Marescaux

Abstract

This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.

Keywords

video-assisted approach, parathyroidectomy

Media type

Surgical video

Duration

08'20''

Publication

2008-01

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E-publication

WeBSurg.com, Jan 2008;8(01).
URL: http://www.websurg.com/doi-vd01en2262.htm

Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique

1. Case history 00'15''

The video shows a case of a 50-year-old patient presenting with primary hyperparathyroidism associated with a 2-year clinical history of depression and articular pain. Blood examination showed a hypercalcemia associated with hypophosphoremia and a high PTH level. Neck ultrasonography confirms the presence of a right superior parathyroid adenoma.

2. Surgical incision 00'39''

In such cases, we use the video-assisted technique as described by Paolo Miccoli. A 2.5cm transverse neck incision is performed 1cm above the sternal manubrium.

3. Exposure of operative field (note dissection and retraction of omohyoid muscle) 00'51''

The platysma is divided and we control tow anterior jugular veins. Contrarily to Miccoli’s technique however, we dissect and retract the omohyoid muscle in order to help us access quickly and precisely the jugulocarotid groove. In this way we obtain an excellent view of the operative field.

4. Anatomy of superior parathyroid gland 01'42''

Here we observe the usual location of the superior parathyroid gland on the posterior surface of the middle third of the thyroid lobe approximately 1 cm above the junction of the inferior thyroid artery and the recurrent nerve. Traction is maintained which allows us to dissect this space gently.

5. Identification of right superior parathyroid adenoma 02'13''

We rapidly identify the adenoma traversed by the inferior thyroid artery seen here in the lower part of the screen. We can observe the variation in colours between the different tissues. This illustration shows the potential sites of superior and inferior ectopic localization.

6. Dissection of parathyroid adenoma 02'54''

We now begin to resect the adenoma by using micro-instruments adapted to this type of surgery. In particular, we find that the use of a 30-degree scope greatly facilitates the operation.

7. Identification and preservation of recurrent laryngeal nerve 03'13''

This optic is most helpful in appreciating the dissection of the inferior laryngeal nerve. The dissection must be done with care as there is a heightened risk of injuring the nerve if we do not identify properly both the nerve itself and its course before dividing the inferior thyroid artery with the Ligasure device. The procedure continues by alternating traction on the adenoma. The objective now is to identify the course of the recurrent laryngeal nerve to allow us to safely divide the gland’s pedicle.

8. Resection of adenomatous gland 05'15''

We proceed with controlled and careful division of the anatomical structures adjacent to the adenoma.

9. Resected specimen 06'57''

The resected gland is 3x2x1cm in size. You can see here that the operative field is fully dry.

10. Evaluation of right inferior parathyroid gland 07'20''

Given the excellent operative field because of the retraction of the omohyoid muscle laterally, we only now need to dissect the superior portion of the thyrothymic tract. We then identify thanks to its typical colour the inferior orthotopic parathyroid gland. Intraoperative PTH assay confirms success of the resection. Pathological examination of the specimen further corroborated that we had got the correct gland. Finally, on postoperative day 1, serum biochemistry confirmed normocalcemia.

11. Operation end 08'10''