| 00'17'' | Case presentation
This is the case of a 60-year-old man, with a clinical history of renal stones, asthenia, psychological disorders, presenting with very high parathyroid hormone serum levels and more than 3 and half millimoles of calcium. Preoperative scintigraphy was negative; the preoperative ultrasonography shows a 1.5cm large mass, supposedly an inferior parathyroid adenoma on the left side. So we are starting with a 1.5cm incision, 2 or 3cm above the sternal notch. The electrocautery has been isolated all along its course, but for a few millimetres on its tip, we are dividing the subcutaneous fat right in the middle. No platysma is expected in the middle of the incision so we go straight to the midline. Very small retractors are used to gain access to the midline, which has to be incised exactly in the middle to avoid any bleeding. See how important it is to avoid bleeding, both in the fatty tissues and in the midline. You can see the muscles slightly darker than the midline. Here the muscles which stay all along their course, you do not need to incise the muscles but just the midline, which is supposed not to bleed. We are now trying to reach the left side under the strap muscles. We are entering the left thyroid space; you can see the left thyroid lobe under the retractor. We have to complete the dissection of the strap muscles on the left side. We are going towards the left thyroid space, dissecting again the muscles.
We now have to divide the middle thyroid vein between clips. What are your landmarks for this surgery? There are 2 retractors, this one is retracting the left thyroid lobe, this is the thyroid lobe, which is partly retracted, and the other retractor is retracting the carotid artery, which is visible here. So we have 3 landmarks: carotid artery, thyroid lobe, which is this one, and the strap muscles are of course completely retracted. The adenoma might be the one, which is appearing in the lower part of the screen, we must distinguish it from the thyroid lobe. Professor Vix suggested an inferior parathyroid adenoma. Do you always look for the inferior thyroid artery? Yes, it is this one, we are making it visible. This is the inferior pedicle, and the nerve is supposed to stay underneath the pedicle, but it is now covered by the adenoma, which is quite large. This is the nerve, it is partly covered by the adenoma. Underneath the thyroid, the inferior artery. I am pretty sure that this should be the adenoma, there are some vessels between it and the clip. You can see the small vessels divided. In cases where you are not exactly certain that you are dealing with the adenoma, what special maneuvers do you perform to determine that this is parathyroid and not thyroid? No, I think that I have to dissect the mass, which is supposed to be the parathyroid and then look at the vessels, and above all look for color changes in the mass during dissection. This is exactly what I think is happening; you can see here the difference between the color of the thyroid gland and the darker color of the mass, which is supposed to be the adenoma. The change of color is not due to the dying but because as soon as you start dividing the vessels, you have less blood supply and so the adenoma will change its color. We are going towards the inferior pole of the adenoma, dissecting with small tiny movements of the spatulas. This is probably the thymus, I am quite sure there are no big vessels so I can divide them. What about the instruments you use? They are designed by Karl Storz and can be bought from them; they have been designed according to our suggestions.
I have to open the muscles a little bit more because otherwise I don’t have enough room to dissect the gland entirely, which is an inferior one. Could you give us an indication of the scale there of the size of the adenoma in relation to your instruments? This is the pedicle and I think that the diagnosis of inferior adenoma was correct. According to the ultrasonography, the scale is of around 1.5cm for the adenoma. These instruments have special designs, the tips are around a couple of millimetres wide; the spatula is probably not much larger. The endoscope is a 30 degree, 5mm endoscope. I am putting several clips because we are now grabbing the adenoma. What is the learning curve for this sort of operation? It depends on your experience in endocrine surgery because you need to know about the physiopathology of this disease, and have some dexterity with endoscopes. We are now finishing the dissection and the last cut. You should have a good view of the space of the parathyroid adenoma. It was perfectly located between the inferior thyroid artery and the recurrent nerve. This is the recurrent nerve well isolated with a small inner branch and a main branch, then the thyroid artery, the esophagus, and the thyroid lobe, which is retracted by the retractors. The carotid artery now, so all the typical landmarks of this surgery are carefully evaluated and taken into account before removing the adenoma. It is a general rule to look at the nerve and inferior artery before dissecting the adenoma. Here is the adenoma, the capsule is complete with no ruptures, it measures 1.5cm. The small vessels, you see the clips, we did a nice good ligature of the pedicle. This is the adenoma with its typical brownish color, its size is confirmed, and no doubt that the adenoma was entirely and properly removed. This is the scar, as you can see its length is 1.5cm; we don’t place any drain or suture; we can either put some surgical glue like Dermabond or something similar or just a little Steri-strip. The patient is ready to go home on the same day of the operation, or if you prefer the day after. The 1.5cm incision was performed with a normal knife, then we prepared the midline with standard electrocautery, which has been isolated all along its length except the tip so as to avoid skin injuries. This is the tip, the only part of the blade that is working. Then we use small retractors, these are Army-Navy retractors or called Farabeuf in Europe. These have been designed by ourselves because as you see they have a different length: this part is shorter than the other. We have 3 different lengths, this one is a little bit longer but this branch is even shorter, and this also. They have a little band on the tip just to retract better, particularly for the thyroid lobe, this is important. You have to grab and lift up the thyroid artery, I want to see the recurrent nerve well and then the adenoma. The spatula is of paramount importance and Pierre Roberti is a master in using it, a spatula that has a small hole on its tip, which is an aspirator because it is connected with a tube to drain water, smoke and blood. It is a very important tool and has been designed by ourselves; there is a small wire inside to keep the hole free of small clots. Then we have 2 more spatulas, generally one operator holds the spatula aspirator and the other one holds this spatula. Then we have scissors, very small needlescopic instruments, these instruments are made by Karl Storz as is everything here. Sometimes when you have a particularly large adenoma with a long pedicle, this is also a very useful instrument: this is a sort of hook, the prototype was designed by ourselves and designed by Goldsmith in Providence, a city in Rhode Island. This is a flexible instrument in stainless steel. This is a clip applier, you can also use disposable vascular clips, this is a little too large for neck video-assisted surgery, we would need smaller ones, which are not yet available on the market. The clips generally used by vascular surgeons are 2.5mm.
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Video-assisted parathyroidectomy: left inferior adenoma
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