Minimally invasive video-assisted right parathyroidectomy for hyperparathyroidism

This video demonstrates a minimally invasive approach to excision of a parathyroid adenoma. A mini-incision is placed transversely in the midline and the laparoscope provides a magnified image for dissection. Modified instruments from open surgery are used and all the parathyroid glands can potentially be accessed by this approach. This is the case of a 48-year-old female patient who has complained for several years of bone and muscular pain. Systematic preoperative diagnostic work-up showed hypercalcemia (3.5 mmol/L), hypophosphatemia (0.70 mol/L) and increased PTH levels (180 picograms/mL). A superior right parathyroid adenoma was suspected on cervical ultrasound. A CT-scan was performed preoperatively and a superior left parathyroid adenoma was found. MIBI scintigraphy evidenced an area of increased uptake consistent with this. A 2 cm suprasternal incision is carried out and the left lateral thyroid lobe is approached. The inferior thyroid artery and the left recurrent nerve are identified. These two structures are the major landmarks to correctly identify the parathyroid adenoma, which is then completely dissected before the pedicle is ligated.

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Minimally invasive video-assisted right parathyroidectomy for hyperparathyroidism

Authors

M Vix, J Marescaux

Abstract

This video demonstrates a minimally invasive approach to excision of a parathyroid adenoma. A mini-incision is placed transversely in the midline and the laparoscope provides a magnified image for dissection. Modified instruments from open surgery are used and all the parathyroid glands can potentially be accessed by this approach.
This is the case of a 48-year-old female patient who has complained for several years of bone and muscular pain. Systematic preoperative diagnostic work-up showed hypercalcemia (3.5 mmol/L), hypophosphatemia (0.70 mol/L) and increased PTH levels (180 picograms/mL).
A superior right parathyroid adenoma was suspected on cervical ultrasound.
A CT-scan was performed preoperatively and a superior left parathyroid adenoma was found.
MIBI scintigraphy evidenced an area of increased uptake consistent with this.
A 2 cm suprasternal incision is carried out and the left lateral thyroid lobe is approached. The inferior thyroid artery and the left recurrent nerve are identified. These two structures are the major landmarks to correctly identify the parathyroid adenoma, which is then completely dissected before the pedicle is ligated.

Keywords

minimally invasive video-assisted right parathyroidectomy, hyperparathyroidism

Media type

Surgical video

Duration

09'00''

Publication

2007-11

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E-publication

WeBSurg.com, Nov 2007;7(11).
URL: http://www.websurg.com/doi-vd01en2153.htm

Minimally invasive video-assisted right parathyroidectomy for hyperparathyroidism

1. Schematic of surgery 00'15''

This is the case of a 52-year-old female patient presenting with primary hyperparathyroidism. Preoperative imaging revealed a right inferior adenoma. No other cervical anomaly was detected during the preoperative work-up. A minimally invasive video-assisted approach was therefore decided upon.

2. Initial dissection 00'35''

A 2cm horizontal incision is made 2cm above the sternal manubrium.

3. Sternohyoid muscle 00'42''

The dissection is continued through the subcutaneous tissue paying attention to avoid the anterior jugular veins until the sternohyoid muscle is reached.

4. Sternocleidomastoid muscle 00'55''

Further dissection is then performed laterally to identify the sternocleidomastoid muscle. The fibrous tissue anterior to the jugular vein is dissected in a bloodless manner.

5. Internal jugular vein 01'30''

The jugular vein represents the first cervical landmark.

6. Carotid artery 01'55''

Retraction of the vein reveals the carotid artery behind. The gutter between the jugular vein and the thyroid is dissected cautiously in order to identify the inferior thyroid artery and the recurrent laryngeal nerve. This requires careful detachment of the fatty tissues.

7. Inferior thyroid artery 03'20''

Once these 2 structures have been identified, dissection continues anterior to the junction between nerve and artery to search for the inferior parathyroid gland.

8. Recurrent laryngeal nerve 03'30''

The gland is not found immediately but as the assistant changes the position of the retractor; the parathyroid adenoma can be clearly seen slipping into the dissection plane.

9. Right inferior parathyroid adenoma 03'55''

The adenoma is dissected on all of its surfaces to separate it from the adjoining tissues and to skeletonize its vascular pedicle. All this dissection should remain bloodless and care is taken so that no injury is done to either the recurrent nerve or the adenoma capsule.

10. Skeletonisation and clipping of vascular pedicle 06'56''

Once the pedicle is dissected, two clips are applied and the rest of the gland is separated from the lateral thyroid plane ensuring traction on the fibrous tissue so that any vascular branches that could have been missed are detected. The monopolar cautery hook can be useful to divide some of the larger fibres. When completing the dissection, a small fibre that appears to be more vascularized is discovered.

11. Final dissection 08'12''

Another clip is applied in order to ensure a bloodless resection and the gland is removed. Hemostasis is checked with an intradermal running suture before closure.

12. Resected specimen 08'40''

The adenoma is 13 x 10 x 7 mm in size. The gland has typical adenomatous appearances when divided although this will be confirmed during the pathological examination.