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Vidéos chirurgicales sur WeBSurg
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English - 21'00''
| 00'16'' | Case demonstration
This is a case of primary hyperparathyroidism in a young man probably due to a single adenoma. We have a CT-scan localization and the concordance between magnetic resonance imaging and ultrasonography, the preparatory localization seems to be a left-superior parathyroid adenoma. Parathyroid hormone is around 90, 92, so the case should be a real primary hyperparathyroidism with a high rate of hyperparathyroidism. We start with the same incision as for thyroid surgery: a 1.5cm incision right in the middle of the neck. We are now preparing the midline, we are coagulating right in the middle because we must avoid any bleeding from the muscles. Once the midline has been opened a couple of centimetres along its length, we can enter the thyroid space and search for the parathyroid adenoma. Now you see the strap muscles, we are of course going to explore the left side because the adenoma is supposed to be there. Now the thyroid is going to appear. A good retraction is of paramount importance because as you know parathyroid glands can be exposed as long as you retract medially very energetically the thyroid lobe and the trachea. It is important to dissect the muscles very carefully. Bleeding should be carefully avoided. You see the thyroid lobe, this is retracted medially, here the middle thyroid vein, which must be ligated between clips and also the other has to be prepared. It is very important to ligate this middle thyroid vein in order to open. You see the carotid artery under the spatula and now a second clip has to be placed. I am now cutting between clips. The carotid artery is now more visible. The second vein is to be ligated now. I am preparing the middle vein. I do not have much room to put the clips in here. The assistant is retracting laterally. Once again, cutting these middle veins, this is very important because otherwise I don’t have the access to the space that is supposed to contain the adenoma. I think that the adenoma is appearing in the lower part of the screen now.
We are very close to the esophagus. We are so deep that I can touch the bone plane with my spatula. This reminds me of some ideas me and Gagner and Rubino had about operating on the cervical spine this way. But I am not sure that all the orthopedics and neurosurgeons could agree with me.
I am moving with my spatula; what I am doing is search for the hilus.
Do you think it would be possible to show us where the inferior artery might be? This is it, you see the pedicle. I think this is a very paradigmatic case, you chose well because the adenoma is right underneath the inferior pedicle, which is exactly where the parathyroid should be found. We are now searching for the hilus of the gland, because we also need to isolate it and put the clips. You see how this spatula works because this is also important. We must be sure that the nerve is at a safe distance from the adenoma. I have cut what is supposed to be one of the vascular connections of the gland. I am not sure it is already the hilus. You see the lower pole of the adenoma. What is also important is that the magnetic resonance is absolutely exact in terms of the size of this adenoma. It is really surprising that neither the ultrasonography nor the CT-scan determined exactly the size, but the nuclear magnetic resonance did. The assistant is keeping high and finally I feel more confident now because I have seen the nerve. I would like to see the nerve again. It is very close to the esophagus, it is very thin, it is probably one of the branches or maybe a lymphatic. But anyway I am dissecting very close to the adenoma so I don’t think that there are any risks. We are extracting the gland now. Now the adenoma is out and we just check the last adhesions with the spatula, and you see the clip. I would like to show you the adenoma now. It is around 2.5cm long and 1cm large so it is exactly the size that was determined by the ultrasonography, particularly by the nuclear magnetic resonance. I think it is good to say that magnetic resonance is rarely used for this kind of preoperative imaging but can be very accurate and this is a case where it was accurate. We would like to show you the length of the incision at the end of the procedure. Of course, the length of the procedure is also important, because if you have to retract for a couple of hours, then the incision will be longer at the end, but for these short procedures, we have no problem. Congratulations because this defines what minimally invasive surgery is.
Can you tell us more about your previous cases, what kind of problems you had when you started off and that you have solved over the years? I think this is my 202nd case performed over 4 years. The main difficulty at the beginning was finding the right way to the adenoma, because the more directly your trajectory is to the target, the simpler is the procedure. The first difficulty was to establish which plane should be followed. One possibility was to make an insufflation between the skin and the platysma like Michel Gagner did, but this turned out to take too long. So we went back to the endocrinological surgical experience, which consists in incising the midline and going directly into the thyroid space. When we started going directly into the thyroid space, we would insufflate for 2-3 minutes just to dissect the thyroid lobe from the strap muscles. Then we realized that a blunt dissection with these small spatulas could be enough and we could avoid the insufflation.
The second step was to find the surgical instruments because they did not exist. We discovered after searches that many specialists had the right tools for us, particularly plastic surgeons, we modified their spatulas. They would use these spatulas to perform the minimally invasive lifting. I have to personally thank Mrs. Storz because she had trust in this operation and allowed us to design these new instruments; her engineers collaborated a lot with us, designing and trying new models of these tools. Now there is a set for video-assisted parathyroidectomy, it is not expensive because all these tools can be re-sterilized and are designed to last. We used these small retractors, I designed the exact shape and size of these instruments, but basically they are in Italy and France as Farabeufs, in the USA they are known as Army-Navy retractors. They have been modified a little bit, you see this shape; they are a little bent. We then use the spatulas, this is the spatula-aspirator, we modified it by getting a probe inside which helps very much because these are very small instruments, so to keep them clean we put a probe inside and it removes all the very thin blood clots. The two or three spatulas; this is also a tool that can be very useful sometimes as it can be shaped with your fingers. It is like a small poke that can load the adenoma and expose the hilus well before getting a clip on it, we haven’t used it today but sometimes it can be useful. We then also use scissors and forceps, these were already available by Storz, we have just modified the length and we are now trying to isolate them in order to coagulate directly with the scissors. This is the endoscope, a very simple 30 degree, 5mm endoscope, you could also try working with a 3.5mm, but what we must remember is that we are not working through a trocar so we have a little bit of light dispersion, so I think you can give up 1.5mm and have it lighter. What I suggest is to use the 5mm and what is of paramount importance is the 30 degree because when you go towards the upper pedicle; if you don’t have the 30 degree, you will never reach it. |
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Video-assisted parathyroidectomy for primary hyperparathyroidism
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