Hindawi Publishing Corporation International Journal of Endocrinology Volume 2011, Article ID 206502, 8 pages doi:10.


Review Article Minimally Invasive Parathyroidectomy
Lee F. Starker, Annabelle L. Fonseca, Tobias Carling, and Robert Udelsman
Department of Surgery, Yale University School of Medicine, P.O. Box 208062, New Haven, CT 06520-8062, USA Correspondence should be addressed to Robert Udelsman, robert.udelsman@yale.edu Received 1 October 2010; Revised 30 December 2010; Accepted 23 March 2011 Academic Editor: Ajai Kumar Srivastav Copyright © 2011 Lee F. Starker et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Minimally invasive parathyroidectomy (MIP) is an operative approach for the treatment of primary hyperparathyroidism (pHPT). Currently, routine use of improved preoperative localization studies, cervical block anesthesia in the conscious patient, and intraoperative parathyroid hormone analyses aid in guiding surgical therapy. MIP requires less surgical dissection causing decreased trauma to tissues, can be performed safely in the ambulatory setting, and is at least as effective as standard cervical exploration. This paper reviews advances in preoperative localization, anesthetic techniques, and intraoperative management of patients undergoing MIP for the treatment of pHPT.

1. Introduction
Primary hyperparathyroidism (pHPT) is a common endocrine disease caused by a single parathyroid adenoma in 85% of patients. Identification and resection of the adenoma leads to cure of the disease. Focused unilateral exploration, that is, minimally invasive parathyroidectomy (MIP) of enlarged hyperfunctioning gland(s) under regional anesthetic techniques, has been advocated for the past three decades [1]. Minimally invasive surgery has been defined as the ability of the surgeon to preform traditional surgical procedures employing novel techniques to minimize surgical trauma [2]. In recent years, a number of new minimally invasive techniques have been developed including open minimally invasive parathyroidectomy (MIP) which we describe in this paper. Other minimally invasive approaches, which we will not describe, include video-guided, radio-guided, and endoscopic parathyroidectomies. Prior to current preoperative localization studies, unilateral surgery for pHPT was preformed based upon results of palpation, esophageal imaging, venography, or arteriography [3, 4]. Unilateral focused cervical exploration was also advocated to reduce the cost and morbidity of surgery while maintaining cure rates [5]. Due to limited exposure obtained during MIP, operative adjuncts are required to confirm the adequacy of resection. The intraoperative parathyroid hormone (IOPTH) assay is now recognized by some experts as the single most useful

adjunct in this setting [6]. Current imaging technology has enabled preoperative localization of the hyperfunctioning gland, thus allowing an increasing number of focused unilateral exploration. Sestamibi with single-photon emission computed tomography (SPECT), ultrasonography, and more recently high-quality four-dimensional CT (4DCT) scans identify hyperfunctioning glands in the majority of patients. MIP is now routinely performed at high-volume centers with excellent cure rates and minimal morbidity. A large number of studies have been published over the last decade describing various techniques in minimally invasive parathyroidectomies, and comparing outcomes to each other and to that of conventional bilateral exploration. Table 1 summarizes these studies. The indications for MIP are identical to those for traditional bilateral neck exploration, including patients with symptomatic disease and those with asymptomatic pHPT in accordance with recently published guidelines [7]. In addition to those patients with overt symptoms and signs, there is a large number of patients with significant neurocognitive derangements with biochemically proven pHPT that could potentially benefit from resection [8–10]. The current role of MIP in patients with documented or suspected familial pHPT is controversial. In the majority of these patients, conventional bilateral exploration is recommended due to the frequency of multiglandular disease [11].

[53] 186 patients (historical cohort) Shindo and Rosenthal 88 patients Retrospective review [54] Rubello et al. [61] 699 patients 298 patients 182-sestamibi 150-MIP 140 patients 55 patients Retrospective study IOPTH (not used as management aid) 97. [50] 167 patients (80 IOPTH monitoring. [56] Aarum et al. [62] Caudle et al. or CT scan Pre-op sestamibi scan or ultrasound Pre-op sestamibi scan Intra-op IOPTH gamma probe IOPTH IOPTH in MIP gamma probe in MIRP Sugino et al. [43] 441 patients Prospective case series Pre-op sestamibi scan or ultrasound IOPTH Barczynski et al.2 International Journal of Endocrinology Table 1: Summary of studies describing technique and outcomes of minimally invasive parathyroidectomy. [55] Lindekleiv et al. [57] Tang et al. [59] Pang et al. [49] Fouquet et al. frozen section Mihai et al. 26 conventional Prospective study Retrospective study Prospective randomized control trial IOPTH Pre-op sestamibi scan or ultrasound IOPTH Pre-op sestamibi scan or IOPTH ultrasound Pre-op sestamibi scan or IOPTH ultrasound Pre-op sestamibi scan or IOPTH gamma ultrasound probe Pre-op sestamibi scan Pre-op sestamibi and ultrasound IOPTH IOPTH 202 patients 50 MIP. Retrospective study 34 open) 500 patients prospective Prospective study Pre-op sestamibi scan Pre-op sestamibi scan + ultrasound for incision placement Intra-op gamma probe Soon et al. [63] Alfadda et al. VAP with decreased pain & need for analgesia Pre-op sestamibi scan Pre-op sestamibi Intra-op gamma probe. 31 MIRP) Study type Retrospective case series Prospective cohort study Prospective study Success rate 100% success 97% success Similar outcomes Pre-op Pre-op sestamibi Pre-op sestamibi scan or ultrasound Pre-op sestamibi Pre-op sestamibi scan. [48] Methods 305 patients (1997–2007) 541 patients 56 patients (25 MIP. [64] Prospective study Prospective study Retrospective study Carling et al. [65] 60 patients 30 MIP. VAP longer Similar outcomes 95% success 91% success 93% success 97% success 96% versus 94% Improved quality of life 98% success 97.4% success IOPTH Multicenter 143 patients (75 MIP. pain). 30 VAP Prospective randomized control trial Pre-op sestamibi and ultrasound IOPTH . [46] Krausz et al.3% success 96% success 93% success 10% conversion to GA (thyroid exploration/conversion to open exploration/patient discomfort) 97% success in both groups. 152 Retrospective study open 152 patients (118 MIP. [60] 452 patients 344 MIRP 47 patients 50 patients 23 MIP. [47] Sevinc ¸ et al. Study Adil et al. [51] VAP) randomized control trial Prospective 48 patients (24-focused Slepavicius et al. [58] Politz et al. [52] randomized control exploration) trial Prospective study Shindo et al. 68 prospective Hessman et al. 87 without Prospective study IOPTH monitoring) 200 patients Prospective study 97% versus 93% 72% success 28% converted to open Similar outcomes (conversion rate. ultrasound.

The accuracy of lateralization and correct quadrant localization of parathyroid tumors is highly variable. A major limitation of sestamibi scans is due to the coexistence of thyroid nodules..e. which generates three-dimensional images [12–15].g. A few studies which have evaluated this phenomena saw significant drops in sensitivity of sestamibi scintigraphy when utilized in the presence of a nodular thyroid gland. lymph nodes and metastatic tumors) that can mimic parathyroid adenomas thereby causing false-positive results. Therefore. Technetium 99m methoxyisobutylisonitrile (sestamibi) was initially introduced for cardiac scintigraphy and was incidentally found to be concentrated in parathyroid adenomas [16]. including sestamibi-technetium 99m scintigraphy.. The most commonly used modality is sestamibi with SPECT. 21]. Sestamibi is a monovalent lipophilic cation that diffuses passively through cell membranes and accumulates almost exclusively in mitochondria following negative membrane potentials [17]. while small adenomas (<600 mg) with low (<20%) numbers of oxyphil cells are usually associated with a negative scan [25]. [72] IOPTH Pre-op sestamibi and/or ultrasound Pre-op sestamibi scan IOPTH IOPTH In the rare cases (<1%) of suspicion of parathyroid carcinoma as the etiology of pHPT. These concomitant abnormalities have been reported to be as high as 40–48% [22]. 25-GA 146 patients 84 MIP (79%) 1361 patients 268 patients 50 patients 25-MIVAP. and magnetic resonance imaging (MRI). 96% versus 81% [23] and 92% versus 53% [24]. The normal parathyroid gland is generally too small to be visualized sonographically. especially for ultrasound.8% success Prospective randomized control trial Decreased operating time with MIP Decreased operative time and post-op need for analgesia with RA Intra-op gamma probe. [70] Rubello et al. especially H¨ urthle cell neoplasms or other metabolically active tissues (e. [71] Bergenfelz et al. Parathyroid oxyphil cell content >20% quadruples the rate of obtaining a positive sestamibi scan. [66] Ollila et al. 29]. high mitochondrial density is associated with sestamibi uptake by human parathyroid tissue [18.. [69] Grant et al. some studies suggest improved sensitivity of parathyroid tumor localization using sestamibi with SPECT and surgeon-performed US [30]. 25-open Pre-op sestamibi scan and ultrasound Pre-op sestamibi scan or ultrasound Mekel et al. a radical resection (i. ultrasonography. The sensitivity of sestamibi scans in the literature is 80% [20. 2. 19]. The term is derived from three-dimensional CT scanning with the additional dimension referring to .International Journal of Endocrinology Table 1: Continued. noninvasive. the parathyroid tumor cell content may be related to sestamibi uptake. 4DCT scan is similar to CT angiography. an en bloc resection of the involved hyperfunctioning gland with concomitant ipsilateral thyroid lobectomy) should be undertaken during the initial procedure [12]. Four-dimensional CT scan (4DCT) is a promising new parathyroid imaging technique. Study Cohen et al. whereas the parathyroid enlargement seen in pHPT is often identified as a homogeneously hypoechoic extrathyroidal ovoid mass. Additionally. but its limitations include both operator dependency and being limited to application in the neck because it cannot image mediastinal tumors.6% success Retrospective review 96% success Prospective randomized control trial Prospective study 54% open exploration Retrospective review 44% MIP (2% conversion) Retrospective review 96. some surgeons suggest reserving sestamibi with SPECT for patients with negative US or as an adjunct to patients with concomitant thyroid disease [28. and inexpensive. Additionally. [67] Methods 130 patients 77 patients Study type Success rate Pre-op Pre-op sestamibi scan and/or ultrasound Pre-op sestamibi scan Intra-op IOPTH 3 Retrospective review 98. Similar to sestamibi with SPECT. Several noninvasive preoperative localization methods are available. the ability of an ultrasound to detect the parathyroid abnormality is reduced in milder forms of pHPT (i. selective frozen section IOPTH Miccoli et al. sestamibi with SPECT does not provide detailed anatomical depiction and can only rarely detect double adenomas and multiglandular hyperplasia [26]. due to operatordependence. Preoperative Imaging The development and refinement of parathyroid imaging has been essential for the development of MIP in the treatment of pHPT. Thus. computed tomography (CT). Additionally. Ultrasound (US) is effective.e. [68] 51 patients 26-RA. only mildly elevated PTH and calcium levels) and in obese patients [27].

(b) Corresponding cervical ultrasound from the same patient showing a large hypoechoic cystic parathyroid adenoma (arrow). with patients remaining conscious during exploration.. Intravenous sedation is maintained to alleviate patient anxiety while maintaining a patient who is capable of phonating. Regional anesthesia for the resection of hyperfunctioning parathyroid glands avoids potential complications associated with general anesthesia. however. Unilateral infiltration posteriorly at Erb’s point (located on the posterior border of the sternocleidomastoid muscle midway between its attachments to the mastoid process.16 cm Trv Lt Thyroid Mid (b) 3. Conversely. The regional block can be performed by the surgeon. the cure rates are excellent in experienced hands. concern for parathyroid carcinoma. and patient discomfort [3]. left inferior. the operating surgeon may assess functional status of phonation. and interventional radiologists can obtain additional samples from a region in which a subtle but potentially significant PTH gradient is detected [32].. persistently elevated intraoperative PTH levels. The left thyroid lobe (T). right superior. compared with normal parathyroid glands and other structures in the neck (Figure 1). and left internal jugular vein (IJ) are indicated. Regardless of the reason for conversion in all cases. and the clavicle) and along the anterior border of the sternocleidomastoid muscle on the side of the localized gland and along the area of incision provides excellent analgesia during virtually every case. the changes in perfusion of contrast over time. Rapid PTH measurements have been successfully employed in the angiography suite. Intravascular infiltration of local analgesic agents must be avoided. CCA: common carotid artery. when these imaging studies were used to lateralize hyperfunctioning parathyroid glands to one side of the neck.e. which has been associated with up to a 5% risk of vocal cord changes and damage [35]. just prior to incision after mild intravenous sedation has been administered (Figure 2). conversion should be CCA IJ TR CCA IJ E (c) Figure 1: Preoperative imaging in primary hyperparathyroidism. Anesthesia The majority of parathyroid explorations are performed under general anesthesia utilizing either a standard general endotracheal tube (ETT) or a laryngeal mask airway (LAM). high-volume centers have utilized monitored anesthesia care (MAC) with local and regional anesthesia. parathyroid 4DCT has mainly been . The images provide both anatomic and functional information (based on changes in perfusion) in a single study that the operating surgeon can easily interpret. the sensitivity of 4D-CT (70%) was significantly higher than sestamibi imaging (33%) and ultrasonography (29%) [31].92 cm Dist 1.4 International Journal of Endocrinology used as an adjunct to other imaging modalities in the remedial setting [31]. which includes endotracheal intubation. Furthermore. discordant. invasive localization procedures such as selective parathyroid venous sampling (SVS) with measurements of PTH may be indicated. In a study by Rodgers et al. Even in patients with negative. when used to localize parathyroid tumors to the correct quadrant of the neck (i. trachea (Tr). IJ: internal jugular vein. T: trachea. (c) Four-dimensional parathyroid CT scan depicting an ectopically positioned left superior paraesophageal parathyroid adenoma (arrow). difficulty in ensuring the safety of the recurrent laryngeal nerve. the sternum. 4DCT displayed improved sensitivity (88%) over sestamibi imaging (65%) and ultrasonography (57%). Exquisitely detailed multiplanar images are obtained to accentuate the differences in the perfusion characteristics of hyperfunctioning parathyroid glands (i. We use 1% lidocaine containing 1 : 100000 epinephrine employing a total of 20 mL.e. (a) Sestamibi with SPECT displaying focal retention in the left lower position (arrow) after 30 and 75 minutes washout. like venous localization. Ultrasonography can be employed to guide preoperative aspiration of a putative parathyroid gland in which PTH is measured to confirm that the suspected tissue is parathyroid. Moreover. or left superior).. rapid uptake and washout). To date. or unconvincing preoperative imaging studies. respectively. This technique. should be reserved for remedial cases [33]. Conversion to general anesthesia is occasionally performed and may be due to concomitant thyroid pathology. right inferior. 30 min 75 min (a) RS P 0 T Tr PAd IJ 2 2D 55% C 66 P low Res 1 3 Dist 1. E: esophagus.

Copyright 2002. Lippincott Williams & Wilkins). and a screen is used to protect the patient’s face from the operative field. with permission. Moderate sedation is administered. (b) Local infiltration is also performed along the anterior border of the SCM [2]. with permission.6% conversion to general anesthesia in a study of 441 consecutive patients [25]. the PTH level fails to decline after resection. (From [34].International Journal of Endocrinology 5 Great auricular n. (From [36]. intraoperative PTH monitoring was introduced and allowed for a biochemical alternative to direct fourgland visualization [41]. and further exploration is required. 4. and a regional cervical nerve block is then administered as described. Copyright 2002. which is used for medication and fluid administration. The patient is transported to the operating room and placed in the semifowler position. serial blood draws are obtained. done in a controlled fashion with protection of the surgical field [3]. the recurrent laryngeal nerve is protected. and a single baseline PTH level is obtained in the preoperative holding area. and the anterior compartment of the neck entered the median raphe is mobilized. thus indicating residual abnormal parathyroid tissue. (a) A superficial cervical block is administered posterior and deep to the sternocleidomastoid muscle (SCM. and the adenoma is excised. The patient is awake. and a fan is used to blow room air gently toward his or her face to minimize the sensation of claustrophobia. The anesthesia personal will require access to the intravenous line to obtain PTH measurements (Figure 3) [34]. Lippincott Williams &Wilkins). 3 2 (a) (b) Figure 2: Cervical block anesthesia. followed by a local field block [3]. Air directed to patient’s face to minimize claustrophobia Site of intraoperative sampling of parathyroid hormone Fan Figure 3: The patient has a large-bore peripheral intravenous line inserted. In some patients. multiglandular disease could not be accurately ruled out without directly visualizing at least all four glands. An abbreviated Kocher incision (approximately 3 cm) is then made. We recently reported a 10. as well as sampling for parathyroid hormone (PTH) levels. Supraclavicular n. the parathyroid adenoma visualized. Once resection is complete. 1 1 Anterior cervical n. Intraoperative PTH monitoring is feasible because PTH has a short half-life of the hormone (3–5 minutes). Prior to this. Procedure A 20-gauge intravenous catheter is placed in the antecubital fossa. 1). Intraoperative Parathyroid Hormone Monitoring In 1990. 5. . Adequacy of resection is confirmed when the patient’s preoperative baseline PTH level decreases by at least 50% and returns to the normal range [36–40].

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