Diversification of minimally invasive parathyroidectomy for primary hyperparathyroidism: minimally invasive video-assisted parathyroidectomy and minimally invasive open videoscopically magnified parathyroidectomy with local anesthesia

With the expansion of minimally invasive parathyroid surgery for primary hyperparathyroidism, new approaches and techniques evolved, creating new surgical algorithms with consequences for indication for surgery and patient selection. The presented methods of selective, minimally invasive parathyroidectomy represent this development of diversification. Minimally invasive video-assisted parathyroidectomy (MIVAP) has advanced to bilateral exploration, avoiding preoperative localization other than ultrasonography. Furthermore, a new technique of minimally invasive open parathyroidectomy with the option of videoscopic magnification under local anesthesia (MIPLA) for localizable adenomas is introduced. A series of 103 patients were operated on for primary hyperparathyroidism using minimally invasive procedures: 87 with MIVAP and 16 with MIPLA. With MIVAP the conversion rate to cervicotomy for multiglandular disease or technical difficulties was 16% (n = 14). With MIPLA, conversion to general intubation anesthesia or additional sedation was necessary in four patients. A transient laryngeal nerve palsy was observed in one patient with MIVAP. Bilateral exploration was carried out during 29 MIVAPs and 2 MIPLAs. The duration of surgery differed, with a median 63 minutes for MIVAP and 39 minutes for MIPLA. Surgery under local anesthesia was completed in 4 patients with MIVAP and in 14 with MIPLA. All patients were cured of primary hyperparathyroidism. Preliminary results of diversified procedures demonstrate effects regarding omission of preoperative diagnostics, overall cost reduction, and increasing patient selection for selective parathyroid surgery because of primary hyperparathyroidism.     

The actual role of classic bilateral cervicotomic approach for primary hyperparathyroidism in the era of minimally invasive surgery

Recent advances in preoperative localisation of parathyroid adenomas and intraoperative prove of complete removal of hyperfunctioning parathyroid tissue have fostered less invasive operative procedures which directly target the diseased gland. Such strategies have partially replaced the previous gold standard procedure of bilateral neck exploration. We herein report on our own series of 1099 consecutive operations for primary hyperparathyroidism performed in a 16 year period and provide information and arguments for primary bilateral exploration in selected cases. 97.1% of patients were cured by the primary operation. From 1999 through 2001, 200 patients underwent bilateral neck exploration, whereas 63 unilateral operations were performed (33 patients were treated by minimally invasive video-assisted parathyroidectomy (MIVAP) and 30 by minimally invasive open parathyroidectomy (MIOP). In the remaining 200 patients minimally invasive unilateral parathyroid surgery was not feasible due to concomitant goiter (n = 102), lack of preoperative localisation (n = 30), previous thyroid surgery (n = 10), suspected multiglandular disease (n = 10), or other reasons (n = 8). In 40 patients the decision for bilateral neck exploration was made despite feasibility of a unilateral approach. CONCLUSION: Whereas unilateral exploration produced excellent cure rates in older patients, it is not recommended in patients with a high likelihood of multiglandular disease, presence of a large or multinodular goitre, high PTH levels, giant adenoma, unclear MIBI scans or an unreliable OPTH assay. Contrasting recent reports on a dramatic shift of technique towards minimally invasive procedures unilateral parathyroid surgery may not be preferably advisable in a majority of patients from countries with insufficient iodine supplementation.     

Video-assisted parathyroidectomy: learning curve]

STUDY AIM: Minimally invasive video-assisted parathyroidectomy (MIVAP) was introduced in 1997 for the treatment of sporadic primary hyperparathyroidism (sPHPT). The study aim was to review the entire series of patients operated on in order to analyse the learning curve of this procedure. PATIENTS AND METHODS: Between February 1997 to January 2001, 185 patients underwent MIVAP. All these patients were divided into three groups: group A (GA) included 63 patients operated on between February 1997 and September 1998; group B (GB) 64 patients operated on between October 1998 and January 2000; Group C (GC) 64 patients operated on between January 2000 and January 2001. Mean operative time, complications and conversions rates of the three groups were compared. RESULTS: The three groups were well matched for age and gender. Mean operative time was significantly shorter in patients of GC (28.3 +/- 13.6 min) when compared with GA (62.3 +/- 24.6 min) and GB (48.4 +/- 18.1 min). Conversion was required in 3 cases of GA (4.8%), in 8 cases of GB (12.8%) and in 4 cases of GC (6.5%). One transient postoperative recurrent nerve palsy and 4 cases of transient postoperative hypocalcemia were observed among patients of GA. No complications were registered in the other groups. CONCLUSIONS: This study shows that with increasing experience, the operative time of MIVAP was dramatically reduced, as well as postoperative complications rate. The higher percentage of conversion in groups B and C may be explained by the fact that, with increasing experience, more difficult and ambiguous cases were operated with this technique.     

Minimally invasive video-assisted parathyroidectomy is a safe procedure to treat primary hyperparathyroidism

IntroductionCervical exploration to identify the four parathyroid glands was considered to be the gold standard for management of primary hyperparathyroidism. In recent years, advances in preoperative localizing techniques have led to the use of more targeted, minimally invasive procedures to remove parathyroid glands. We present our series of patients who underwent Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) procedures and our results in treating primary hyperparathyroidism.MethodsPatients who underwent video-assisted parathyroidectomy were identified from a prospectively maintained database. Clinico-pathological data including indications for surgery, complications, conversion to open procedure and success of surgery were obtained from clinical notes.ResultsA total of 56 patients underwent MIVAP between 2002 and 2010 at a district general hospital setup. The clinical indication was diagnosed primary hyperparathyroidism. Preoperative localization was attempted in all patients by sestamibi and high resolution ultrasound scans. The median age of patients was 65 years (32–82) and the median operating time was 78 min (20–168). Conversion to open procedure was done in 8/56 (14%) cases. The reason for conversion was failed exploration in 5 patients, inability to retrieve a very large friable adenoma in one patient, lipo-adenoma in one patient and very small parathyroid adenoma in one patient. Postoperative complications happened in one patient (2%) who developed postoperative sepsis resulting in temporary recurrent laryngeal nerve (RLN) palsy. All but 5 patients became normo-calcaemic following surgery.ConclusionMIVAP is a safe and effective procedure for treating patients with primary hyperparathyroidism. It also allows classical 4 gland exploration, whenever necessary.     

Results of Video-assisted Parathyroidectomy: Single Institution’s Six-year Experience

Endoscopic surgery for primary hyperparathyroidism (PHPT) started in 1996 with a parathyroidectomy performed by Michel Gagner. The technique we propose and have been using for 6 years is based on a unique central access and external retraction. From February 1997 to October 2003, 370 of 520 patients affected with PHPT (71%) underwent minimally invasive video-assisted parathyroidectomy (MIVAP). There were 72 men and 298 women, with a mean age of 55.8 years. Twenty-four patients (6.5%) of the 370 in this series underwent MIVAP under loco-regional anesthesia, and the others had general anesthesia. Eleven patients were lost to follow-up. Surgical cure of PHPT was achieved in 353 patients (98,3%), as confirmed by a median follow-up of 35.1 months (range: 2–82 months). Video-assisted exploration was successfully performed in 350 patients (94%). The mean operative time was 36.2 minutes. In 21 cases (5.6%) a concomitant procedure was performed: a thyroid lobectomy in 14 cases and a total thyroidectomy in 7 cases. Patients were generally discharged the day after surgery. Most of the patients (91%) were satisfied with the cosmetic result 6 or more months after the procedure. Complications developed in 14 cases: 10 cases (2.7%) of transient hypoparathyroidism 3 cases (0.8%) of definitive palsies of the recurrent nerve, and 1 case of postoperative bleeding (0.27%). After 6 years of experience, MIVAP appears to be as safe and curative as traditional surgery, with better cosmetic results and better postoperative outcome.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14-17, 2004.     

Minimally invasive video-assisted parathyroidectomy – selective approach to localized single gland adenoma

Background: The valid operative standard for primary hyperparathyroidism (pHPT) consists of cervicotomy and presentation of all parathyroid glands. This operative technique features the macroscopic identification of the responsible adenoma. It also has the advantage of detecting multiglandular disease. The increasing sensitivity of preoperative localization methods and the possibility of intra-operative measurement of parathyroid hormone prepared the way for minimally invasive procedures. Methods: All patients with pHPT were examined by cervical sonography and sestamibi scintigraphy of the parathyroid glands. Patients eligible for the described procedure had to comply to the following inclusion criteria: biochemical evidence of pHPT, localization of one unequivocally enlarged parathyroid gland on two corresponding imaging results; no former surgery or radiation to the neck; no multinodular goiter; no suspected carcinoma of the thyroid; and no secondary or recurrent hyperparathyroidism. We used an operative technique first described by Miccoli in 1997. Before preparation and at 2, 10 and 15 min after exstirpation of the parathyroid adenoma, peripheral blood was drawn. The operation was terminated when a 50% decrease of preoperative PTH levels was reached. Results: During a 12-month period (1 December 1997 to 30 November 1998), 13 patients with pHPT of a total of 59 patients (22%) with hyperparathyroidism (pHPT and sHPT) were operated on employing this minimally invasive procedure. In three patients, the operative technique had to be converted to the conventional procedure due to superior adenomas in two cases and a dorsoesophageal adenoma in one case. The procedure could thus be successfully completed in ten patients. The overall failure rate was zero in all patients with regard to the underlying disease. There was one temporary, recurrent laryngeal-nerve palsy. The mean overall length of the hospital stay was 3 days. Conclusion: The minimally invasive video-assisted parathyroidectomy for localized single-gland adenoma is a new and attractive surgical therapy option for primary hyperparathyroidism due to improved patient comfort, shortened length of hospital stay and favorable cosmetic results. This may lead to one-day surgery and, therefore, to a reduction of overall costs. Received: 8 December 1998 Accepted: 3 June 1999     

Limits and drawbacks of video-assisted parathyroidectomy

BACKGROUND: Minimally invasive video-assisted parathyroidectomy (MIVAP) is a novel minimally invasive approach to primary hyperparathyroidism (PHPT). It is a gasless operation characterized by a single central incision and external retraction. This paper describes the drawbacks and limitations of this procedure based on a 5-year experience and 260 operations. METHODS: Of 364 patients with PHTP, 260 were selected for MIVAP. In most patients a unilateral minimally invasive exploration was performed. RESULTS: MIVAP was carried out successfully in 239 patients with a mean operating time of 40 (range 20-180) min. Conversion to cervicotomy was required in 21 patients (8.1 per cent). Complications included recurrent nerve palsy in two patients (0.8 per cent), haemorrhage that required reoperation 6 h after parathyroidectomy in one patient (0.4 per cent) and transient hypoparathyroidism in six patients (2.5 per cent). In five patients (2.1 per cent) persistent PHPT developed shortly after surgery. CONCLUSION: After 5 years of experience, MIVAP appears to be feasible, safe and applicable to the majority of patients with PHPT.     

Minimally Invasive Video-assisted Parathyroidectomy: Multiinstitutional Study

Unilateral and minimally invasive parathyroidectomies with endoscopic and video-assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video-assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO₂ insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video-assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12-month follow-up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5–5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.     

Minimally invasive video-assisted parathyroidectomy and intraoperative parathyroid hormone monitoring. The first 36 cases and some pitfalls

Background: The success of parathyroid surgery depends on the identification and removal of all hyperactive parathyroid tissue. At this writing, bilateral cervical exploration and identification of all parathyroid glands represent the operative standard for primary hyperparathyroidism (pHPT). However, improved preoperative localization techniques and the availability of intraoperative parathyroid hormone monitoring prepare the way for minimally invasive procedures. Methods: Patients with pHPT and one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, a rapid chemiluminescense immunoassay was used to measure intact parathyroid hormone (iPTH) levels shortly before and then 5, 10, and 15 min after excision of the adenoma. The operation was considered successful when more than a 50% decrease in preexcision iPTH levels was observed after 5 min. Results: Between October 1999 and November 2001, 36 of 82 patients with pHPT were eligible for a minimally invasive approach. A conversion to open surgery became necessary in five patients because of technical problems. In three cases, intraoperative iPTH monitoring showed no sufficient decrease in iPTH values. In these cases, subsequent cervical exploration showed one double adenoma and two hyperplasias, respectively. In two patients we had difficulty interpreting intraoperative iPTH values, resulting in persistent pHPT. Conclusions: Despite the use of high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy, the presence of multiple glandular disease cannot be ruled out completely. Intraoperative iPTH monitoring to ensure operative success is indispensible for a minimally invasive approach. Despite our problems with iPTH monitoring in two patients, we believe that in selected cases, minimally invasive parathyroidectomy represents an attractive alternative to conventional surgery.     

Feasibility of video-assisted bilateral neck exploration for patients with primary hyperparathyroidism and failed or discordant localization studies

Purpose

Minimally invasive video-assisted parathyroidectomy (MIVAP) is generally adopted for patients affected by primary hyperparathyroidism (pHPT) with clear preoperative localization. Standard bilateral neck exploration (BNE) is considered the obligate surgery for patients with unlocalized glands. We reviewed our experience of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies.

Methods

From a prospective series of 576 MIVAP for pHPT, 107 patients (19 males, 88 females; mean age 58 years) with failed localization studies underwent BNE using the video-assisted technique. Operative time, complications, conversions to standard cervical exploration, and cure rate were analyzed.

Results

MIVAP with BNE was successfully completed in 99 (93 %) patients with 8 conversions. Mean operative time was 57?±?37 min (range 20–180 min). Permanent recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 104 patients (97 %). Five patients required a reoperation in the immediate postoperative period, which achieved cure in four. Two patients remained with persistent disease; one developed recurrence disease 3 years after the first exploration.

Conclusion

In experienced hands, video-assisted BNE for pHPT is feasible and safe and provides results equivalent to the conventional open technique.     

A new surgical technique for thoracic parathyroid glands: video-assisted thoracoscopy with intraoperative Tc-MIBI scintigraphy

Ectopic mediastinal parathyroid glands are uncommon (1-11% of all cases of hyperparathyroidism). Median sternotomy used to be performed to resect them, with large and painful incisions that prolonged the length of hospital stay. Current imaging techniques (thoracic computed tomography and Tc-mibi scan) can accurately locate the ectopic glands, allowing minimally invasive exploration. We report a new surgical technique: video-assisted thoracoscopic resection associated with intraoperative Tc-mibi scintigraphy for ectopic mediastinal parathyroid glands. This technique allows minimally invasive access and reduces complications and length of hospital stay. Therefore we believe that video-assisted thoracoscopy could become the technique of choice in patients with high surgical risk and a fifth ectopic parathyroid gland. We report the case of a 49-year-old man in whom surgery was successful.     

Impact of localization studies on feasibility of minimally invasive parathyroidectomy in an endemic goiter region

BACKGROUND: A localized single-gland disease is the basis for minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (PHPT). (99m)Tc sestamibi scanning (MIBI) and high-resolution Doppler ultrasonography (US) are well-established techniques used to localize enlarged parathyroid glands. Additionally, US enables physicians to diagnose subclinical thyroid abnormalities. The aim of this study was to optimize localization results, applying a combined interpretation of MIBI and US, and to analyze the influence of these results on the feasibility of MIP (endoscopic/video-assisted and open) in an endemic goiter region. STUDY DESIGN: One hundred fifty consecutive patients with sporadic PHPT were prospectively subjected to MIBI and US to localize parathyroid lesions and to review the morphology of the thyroid gland. Bilateral cervical exploration was performed in all patients. The feasibility of MIP was calculated retrospectively on the basis of surgical findings and biochemical outcomes at least 12 months postoperatively (normocalcemia in 148 of 150 patients [99%]). RESULTS: Forty-five percent of patients (67 of 148) would have been suitable for minimally invasive endoscopic or video-assisted parathyroid exploration. These procedures would have succeeded in 38% of patients (56 of 148). Sixty-four percent (94 of 148) would have been suitable for minimally invasive open parathyroidectomy, which would have succeeded in 55% (82 of 148 patients). CONCLUSIONS: Not all patients are suitable for MIP. A combined interpretation of MIBI and US results is helpful in planning targeted exploration. In an endemic goiter region minimally invasive open parathyroidectomy is applicable in significantly more patients than is endoscopic and video-assisted MIP.     

Minimally Invasive Video-Assisted Parathyroidectomy Versus Open Minimally Invasive Parathyroidectomy for a Solitary Parathyroid Adenoma: A Prospective, Randomized, Blinded Trial

Background A variety of minimally invasive parathyroidectomy (MIP) techniques have been currently introduced to surgical management of primary hyperparathyroidism (pHPT) caused by a solitary parathyroid adenoma. This study aimed at comparing the video-assisted MIP (MIVAP) and open MIP (OMIP) in a prospective, randomized, blinded trial. Materials and Methods Among 84 consecutive pHPT patients referred for surgery, 60 individuals with concordant localization of parathyroid adenoma on ultrasound and subtraction Tc^99m-MIBI scintigraphy were found eligible for MIP under general anesthesia and were randomized to two groups (n = 30 each): MIVAP and OMIP. An intraoperative intact parathyroid hormone (iPTH) assay was routinely used in both groups to determine the cure. Primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. Secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within 7 postoperative days (SF-36), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. Results All patients were cured. In 2 patients, an intraoperative iPTH assay revealed a need for further exploration: in one MIVAP patient, subtotal parathyroidectomy for parathyroid hyperplasia was performed with the video-assisted approach, and in an OMIP patient, the approach was converted to unilateral neck exploration with the final diagnosis of double adenoma. MIVAP versus OMIP patients were characterized by similar operative time (44.2 ± 18.9 vs. 49.7 ± 15.9 minutes; P = 0.22), transient hypocalcemia rate (3 vs. 3 individuals; P = 1.0), lower pain intensity at 4, 8, 12, and 24 hours after surgery (24.9 ± 6.1 vs. 32.2 ± 4.6; 26.4 ± 4.5 vs. 32.0 ± 4.0; 19.6 ± 4.9 vs. 25.4 ± 3.8; 15.5 ± 5.5 vs. 20.4 ± 4.7 points, respectively; P < 0.001), lower analgesia request rate (63.3% vs. 90%; P = 0.01), lower analgesic consumption (51.6 ± 46.4 mg vs. 121.6 ± 50.3 mg of ketoprofen; P < 0.001), better physical functioning aspect and bodily pain aspect of the quality of life on early recovery (88.4 ± 6.9 vs. 84.6 ± 4.7 and 90.3 ± 4.7 vs. 87.5 ± 5.8; P = 0.02 and P = 0.003, respectively), shorter scar length (17.2 ± 2.2 mm vs. 30.8 ± 4.0 mm; P < 0.001), and higher cosmetic satisfaction rate at 1 month after surgery (85.4 ± 12.4% vs. 77.4 ± 9.7%; P = 0.006). Cosmetic satisfaction was increasing with time, and there were no significant differences at 6 months postoperatively. MIVAP was more expensive (US$1,150 ± 63.4 vs. 1,015 ± 61.8; P < 0.001) while the mean hospital stay was similar (28 ± 10.1 vs. 31.1 ± 9.7 hours; P = 0.22). Differences in serum calcium values and iPTH during 6 months of follow-up were nonsignificant. Transient laryngeal nerve palsy appeared in one OMIP patient (P = 0.31). There was no other morbidity or mortality. Conclusions Both MIVAP and OMIP offer a valuable approach for solitary parathyroid adenoma with a similar excellent success rate and a minimal morbidity rate. Routine use of the intraoperative iPTH assay is essential in both approaches to avoid surgical failures of overlooked multiglandular disease. The advantages of MIVAP include easier recognition of recurrent laryngeal nerve (RLN), lower pain intensity within 24 hours following surgery, lower analgesia request rate, lower analgesic consumption, shorter scar length, better physical functioning and bodily pain aspects of the quality of life on early recovery, and higher early cosmetic satisfaction rate. However, these advantages are achieved at higher costs because of endoscopic tool involvement. The paper was presented at the 41st World Congress of Surgery, 21– 25 August 2005, Durban, South Africa.     

Randomized clinical trial comparing regional and general anaesthesia in minimally invasive video-assisted parathyroidectomy

BACKGROUND: This randomized clinical trial was performed in a single institution to compare the results of minimally invasive video-assisted parathyroidectomy (MIVAP) conducted under regional anaesthesia (RA) or general anaesthesia (GA). METHODS: Fifty-one patients undergoing MIVAP for primary hyperparathyroidism were assigned randomly to either RA (26 patients) or GA (25). RA involved a bilateral deep cervical block, and local infiltration of the incision site with a mixture of 0.25 per cent lignocaine and 0.15 per cent bupivacaine. GA was induced by intravenous administration of propofol, remifentanil and rocuronium bromide. RESULTS: The two groups were matched for age, sex, adenoma size, and preoperative serum calcium and parathyroid hormone levels. The interval from skin incision to closure was similar in the two groups (27.6 and 25.8 min for RA and GA respectively), whereas the total operating time (from induction of anaesthesia to return to the ward) was significantly lower with RA (72.1 versus 90.2 min; P = 0.001). The postoperative requirement for pain medication, measured in terms of amount of ketorolac administered at the request of the patient, was significantly lower in the RA group (28.5 versus 80 mg/day; P < 0.001). CONCLUSION: MIVAP performed under RA was associated with a shorter overall operating time and a reduced need for postoperative pain relief.     

Minimally invasive video-assisted thyroidectomy: five years of experience

BACKGROUND: In the last decade, development of videolaparoscopic surgery allowed several operations to be performed with minimally invasive techniques, making them less invasive and painful. Neck surgery was also involved in this effort, in spite of the skepticism shown by some authors. STUDY DESIGN: Minimally invasive video-assisted thyroidectomy was developed in 1998, and since then, about 600 operations have been performed. Access was the same as was previously described for parathyroidectomy; it was based on a small central incision (1.5 cm) and on external retraction without neck insufflation. RESULTS: From July 1998 to October 2003, 579 patients were selected from 5,450 for minimally invasive video-assisted thyroidectomy. The operation consisted of a total thyroidectomy in 312 patients and lobectomy in 267 patients. Mean operative time was 41 +/- 19.5 minutes (range 15 to 120 minutes) for lobectomy and 51.6 +/- 18.8 minutes (range 30 to 140 minutes) for total thyroidectomy. Postoperative hospital stay was 24 hours (overnight discharge) for all patients. Complications were postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). CONCLUSIONS: After 5 years of experience using this approach for various indications, we achieved a good esthetic result with an operative time comparable to that of conventional open surgery. Minimally invasive video-assisted thyroidectomy was found to be a safe operation, with advantages over traditional procedures represented by better cosmetic outcomes and postoperative course, as demonstrated by visual analogue scales and statistically analyzed numeric scales.     

Minimally invasive video-assisted kidney transplantation (MIVAKT)

BACKGROUND: Minimally invasive surgery has been applied to nearly all fields of surgery due to its advantages such as reduced morbidity, a better cosmetic outcome, and early recovery. The recent advances in its technique have allowed us to use modified minimally invasive surgery technique in the field of kidney transplantation. MATERIALS AND METHODS: From January 2004 to March 2006, minimally invasive video-assisted kidney transplantation was carried out in 20 patients. Many clinical variables were compared with the conventional method. The operative procedure began with a 7 to 8 cm skin incision. A laparoscopic balloon dissector was used to create the retroperitoneal space for the placement of the grafted kidney. Vascular anastomosis and ureteroneocystostomy were performed under direct vision and with video-assisted TV monitoring. RESULTS: The average length of the wound was 7.8 cm and it was placed below the belt line. The average operating time was 186 min. Less analgesic was given compared with conventional methods. There was one postoperative complication, a mild lymphocele. All patients showed normalized serum creatinine levels within 4 d. All grafted kidneys showed normal findings on the postoperative ultrasound and renal scans. CONCLUSIONS: Minimally invasive video-assisted kidney transplantation is technically feasible and may offer benefits in terms of better cosmetic outcomes, less pain, and quicker recuperation than conventional kidney transplantation.     

Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy

HYPOTHESIS: Minimally invasive surgery for primary hyperparathyroidism has become an accepted part of endocrine surgical practice worldwide. DESIGN: Survey of members of the International Association of Endocrine Surgeons. SETTING: Clinical practice of endocrine surgeons worldwide. MAIN OUTCOME MEASURES: Numbers of parathyroid procedures performed, types of minimally invasive procedures undertaken, and techniques used to ensure completeness of removal of hyperfunctioning parathyroid tissue as reported by the survey respondents. RESULTS: Of 160 surveys completed, 95 (59%) indicate that the surgeons currently perform minimally invasive parathyroidectomy and use this technique on average for 44% of patients with primary hyperparathyroidism. The most common approach is the focused technique with a small incision, either central or lateral (92% [87 respondents]), followed by a video-assisted technique (22% [21 respondents]), and a true endoscopic technique with gas insufflation (12% [11 respondents]). Techniques used to ensure completeness of resection include the quick intraoperative intact parathyroid hormone assay (68% [65 respondents]), a same-day intact parathyroid hormone assay (17% [16 respondents]), and the nuclear probe (14% [13 respondents]). The number of parathyroidectomies performed worldwide increased from 1727 in 1980 to 6977 in 2000 with the average number per surgeon increasing from 23 in 1980 to 45 in 2000. Geographically, 20 (59%) of 34 surveys from the Americas report the use of minimally invasive parathyroidectomy, 23 (56%) of 41 from the Australasian region, and 34 (49%) of 69 from Europe or the Middle East. CONCLUSIONS: The number of parathyroidectomies performed for primary hyperparathyroidism has increased worldwide over the past 20 years. More than half of the surgeons responding to the survey perform minimally invasive parathyroidectomy, with the most using the focused small-incision technique.     

Video-assisted neck exploration for primary and secondary hyperparathyroidism

Background: Minimally invasive surgery (MIS) for primary hyperparathyroidism includes unilateral neck exploration, access via a totally endoscopic approach, and access via a video-assisted procedure. We report herein our initial experience with the video-assisted neck exploration procedure for primary (PHPT) and secondary hyperparathyroidism (SHPT). Methods: Between June 1999 and May 2000, 35 patients were selected for PHPT (n = 25) and SHPT (n = 10). In all cases, video-assisted neck exploration was performed under general anesthesia, leading to selective adenoma removal in PHPT or subtotal parathyroid resection in SHPT. Patient selection was based on the preoperative localization studies (ultrasonography and sestamibi scintigraphy). Results: Five of the 25 patients operated on for PHPT (20%) and three of the 10 patients who underwent surgery for SHPT (30 %) were converted to a conventional surgical technique. The mean operative times in PHPT and SHPT were 48.9 ± 18.7 min and 136.8 ± 18.7 min, respectively. The recurrent laryngeal nerve was identified in 45% of the patients. The median size and weight of the resected parathyroid glands were 1.8 cm (range, 0.9-2.5) and 1 g (range, 0.5-7), respectively. The length of skin incision was 24 ± 1.2 mm. All but one patient are currently cured, with a median follow-up of 6 months (range, 2-13). Postoperative complications included hematoma and transient hoarseness in one patient each (2.85%). The median pain intensity, based on the visual analogue scale (VAS) method, as measured at postoperative day 1 was 0.5 (range, 0-3.6). In the PHPT group, the postoperative hospital stay was <24 h for 30% of the patients and <48 h for 80% of them. conclusion: video-assisted unilateral and bilateral neck exploration is feasible and safe; it represents an attractive and promising minimally invasive approach in phpt and shpt when the surgeon follows the same rules used in the standard conventional approach. its early benefits and long-term results still need to be compared to those of the conventional procedure in a randomized trial.     

Unilateral open and minimally invasive procedures for primary hyperparathyroidism: a review of selective approaches

The currently established procedure for surgical treatment of primary hyperparathyroidism is bilateral exploration and visualization of all four glands to identify an adenoma and exclude multiglandular disease. With the development of improved preoperative localization imaging of the parathyroids using high-resolution ultrasonography and sestamibi scintigraphy, on the one hand, and perioperative control of surgical success with a rapid parathyroid hormone assay on the other, unilateral and minimally invasive techniques have become feasible. For patients with unequivocal localization in preoperative sestamibi scintigraphy and high-resolution ultrasonography of the parathyroid adenoma in probable single-gland disease, the unilateral and minimally invasive parathyroidectomy present a therapeutic option. Perioperative rapid parathyroid hormone assays, although costly, offer immediate supervision of adenoma extirpation and differentiation of single- and multiglandular disease. These methods demonstrate advantages with favorable cosmetic results and lower reported rate of postoperative hypoparathyroidism. These methods are already being practiced in some places under local anesthesia and in an ambulatory setting. This contribution provides an introduction and overview of the currently practiced unilateral and minimally invasive techniques of parathyroidectomy for primary hyperparathyroidism, discussing indications, advantages and disadvantages, and technical differences in the practiced methods. Received: 26 April 1999 Accepted: 22 November 1999     

Radioguided parathyroidectomy via VATS combined with intraoperative parathyroid hormone testing: the surgical approach of choice for patients with mediastinal parathyroid adenomas?

Despite the excellent results with bilateral exploration, minimally invasive parathyroidectomy has become the procedure of choice for patients with hyperparathyroidism in which a single parathyroid lesion can be localized preoperatively. In this article, we discuss a patient who presented with primary hyperparathyroidism for the first time and had a Tc-99m sestamibi scan to localize a single parathyroid lesion in the left, anterior mid-mediastinum. We subsequently performed a radioguided parathyroidectomy via video-assisted thoracoscopic surgery (VATS) to resect this parathyroid adenoma and used intraoperative parathyroid hormone (PTH) testing to confirm cure and avoid neck exploration. We concluded that radioguided parathyroidectomy via VATS combined with intraoperative PTH testing is an effective approach for patients with primary hyperparathyroidism and mediastinal parathyroid lesions, and perhaps should be the technique of choice.