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Vidéos chirurgicales sur WeBSurg
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English - 06'00''
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Keywords: parathyroidectomy,hyperparathyroidism,minimally invasive,video-assisted surgery
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| 00'12'' | Clinical history
It’s a 30-year-old female with classic appearance hyperparathyroidism. She had a localizing study with a MRI that demonstrated a left superior parathyroid adenoma. It looks like it’s deep in the tracheo-esophageal space. The key landmark is the anterior border of the sternocleidomastoid muscle and just here we can palpate the carotid artery, so directly over the carotid artery is our landmark. |
| 00'42'' | Description of landmarks
This is a classic position we have a small shoulder roll underneath. We will go lateral to the strap muscle and this is actually a very interesting approach. It’s sort of a combined endoscopic video-assisted mini-open approach but it has several advantages. What I want to demonstrate is that as endocrine surgeons, we need to have more than one technique that we are able to demonstrate. I think the endoscopic approach has disadvantages and requires a general anesthesia and insufflation and I don’t typically use insufflation in our institution. Basically we put these small narrow retractors in. It’s 1.5 to 2cm incision here.
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| 01'35'' | Skin access and optical positioning
And at the sternal notch there’s a 5mm trocar through which the camera is inserted. We’re looking right at the adenoma and this approach is very nice because you get the benefit of gliding from the video endoscope and also the benefit of a very small incision. Here’s the adenoma we think we’ve not dissected at all yet and this is probably the nerve and this is deep in the retro-esophageal space, we’re behind the esophagus here. And I think that through a small incision it’s very difficult to see unless you make a larger incision. We’ll better demonstrate the nerve in just a moment. The thyroid is up here. We’re behind the thyroid and the esophagus. This is the esophagus underneath the retractor. There’s the adenoma and the nerve is there. We’re going to dissect out the adenoma. Why do you stop the lateral approach? With the insufflation, it was difficult to maintain a working space and this actually demonstrates why the endoscopic approach is not recommended in most cases. This is the nerve right here. Hopefully this is demonstrating the benefit of having a video-endoscopic approach. It’s a big adenoma and it’s very deep and if you’re doing a conventional approach and even if it’s a focused approach and you make your incision in the middle of the neck, you have to make a very large incision to get to the adenoma. I’m going to work away towards the pedicle. However, I often will do a mini-open lateral approach but even then it’s still sometimes hard to see the nerve. This way actually, you have the advantage of both. Here’s the pedicle of the adenoma here. You can see the nerve very nicely and also if things are not going well, you can simply enlarge the incision and still do an open-focused approach. Here’s the pedicle of the adenoma, let’s see if we can find the nerve. The nerve is going to be medial right there. You can see it running underneath. |
| 04'35'' | Recurrent nerve
It’s right underneath the pedicle of the adenoma, which is here. Here’s the esophagus and the adenoma. |
| 04'59'' | Vascular pedicle of adenoma
We’re going to get a clip. I don’t think the vessels are completely divided. It’s a very big pedicle, so we’ll cut partially and we’ll see. It’s important to have more than one technique available as endocrine surgeons. Do you skeletonize to individualize the vein and artery sometimes? I take them together. This is a classic adenoma with deep retro-esophageal space. |
| 05'50'' | End of procedure
I’m going to put it back in and now its out and we’ll look at the anatomy as well. |
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