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Video-assisted parathyroidectomy: right superior adenoma

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Video-assisted   parathyroidectomy:   right   superior   adenoma

作者群
P Miccoli
關鍵字
video-assisted,parathyroid glands,adenoma,endocrinology
媒體類型
期間
24'00''
刊物
2003-02
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Feb 2003;3(02).
URL: http://www.websurg.com/doi-vd01en1404e.htm

Video-assisted   parathyroidectomy:   right   superior   adenoma

1. Case presentation 00'17''
This is the case of a 59-year-old female patient who initially presented with fatigue and had had several episodes of renal colics. The physical exam revealed the cushingoid patient but the workup showed normal cortisol levels. The initial calcemia was of 3.68 and decreased with medical treatment. The cervical CT-scan and nuclear scan showed a right superior parathyroid adenoma, which was located on the right side. The patient has also a Cushing-like pattern and picture typical of fat deposit and very prone to bleed, she has many ecchymoses on her legs and arms so we are trying to avoid any minimal bleeding. From the preoperative diagnosis, there are 2 images that are concordant, ultrasonography and scintigraphy, and they are in favor of localization of an upper parathyroid adenoma since it is very posterior beneath the inferior pedicle close to the esophagus but probably descending in the upper mediastinum. This case is quite challenging. We’re trying to reduce the trauma by performing a minimally invasive parathyroidectomy. We are also trying to minimize the skin, subcutaneous muscle access because this kind of Cushing-like patient is very prone to develop wall complications like infections. Also the septic situation of the patient has been quite serious so we’re now entering the right thyroid space looking for this gland whose size has not been well determined because the lower part of the adenoma escapes an ultrasonographic evaluation. It could probably be as long as 2cm. I’m now dissecting the strap muscles. I’m trying to gain enough room to maneuver. Unfortunately the patient is prone to bleed at any minimal trauma and 2nd technical problem is that the skin and subcutaneous tissue are very thick and so it’s hard to reach the right space. The CT-scan probably showed a thyroid nodule, which is probably the one you’ll see shortly now. It has to be retracted. You see the thyroid is slightly nodular. Here’s the carotid artery on the left of the screen. We’re in the right space but we haven’t enough room to maneuver yet. We generally say that we should stay under 15mL of thyroid volume. The question is: is this the parathyroid adenoma? I think it’s the thyroid nodule but we must be sure. We’re now changing the location of the camera moving from the left side of the patient towards the patient’s head because after this exploration the adenoma is supposed to be very low so we need to explore the upper mediastinum. This is possible only if we change the position of the camera. The adenoma is exactly behind and underneath the inferior thyroid artery and we’re trying to better identify it. So the adenoma has been localized. The surface is bleeding. So you see the thyroid artery, which covers completely and makes our job difficult. You see how the pedicle encompasses -- maybe not larger than we said, it’s very deep. I think it’s quite interesting to look at the space produced by the adenoma growing, which probably started superior to the artery, then going behind the artery and deeper and deeper. There is very small bleeding, which impairs visibility. You have to search for the thyroid artery. You see the artery is pulsating. We control bleeding. We are removing the clip out of the operative field. The problem with seeing the nerve is that it is probably crossed by the thyroid artery. You can see the adenoma, which is supposed to be more than 2cm. Here’s the pedicle of the gland with the small clip. Here’s the adenoma with a small hemorrhage inside. We’re now closing the incision and showing the small subcutaneous bleeding, which is so peculiar of the patient’s disease. This has simply been induced by the retractors and now we’ll show you the same subcutaneous hemorrhage along the arms of the patient.