Endoscopic parathyroidectomy via a lateral neck incision]

A new approach to endoscopic parathyroidectomy is proposed. Via a 15 mm transverse incision on the anterior border of the sternocleidomastoid muscle (SCM), the fascia connecting the lateral portion of the strap muscles and the thyroid lobe to the carotid sheath is divided at the level of the prevertebral fascia. Once enough space has been created, three trocars are inserted: a 12 mm trocar through the incision and two 2.5 mm trocars above and below the first trocar. Carbon dioxide is insufflated at a pressure of 8 mmHg. Unilateral endoscopic parathyroid exploration is then performed with a 10 mm-0 degree endoscopic camera. Once the adenoma has been identified and, if possible the ipsilateral parathyroid gland, the 3 trocars are removed and the adenoma is extracted from the neck after clipping its pedicle directly through the 15 mm incision. Twenty patients with sporadic primary hyperparathyroidism were operated. The adenoma was localized pre-operatively in 14 patients. Intra-operative quick parathyroid hormone assay was used. Exploration was unilateral in 15 patients--Conversion to transverse cervicotomy was performed in 5 cases. In the 50 explored parathyroid areas, 34 glands (68%) were identified by video surgery: 18 of the 21 enlarged glands (86%) and 16 of the 29 normal glands (55%). Mean operating time was 88 minutes (40'-130'). Morbidity consisted of 2 superficial hematomas in the SCM. With a follow-up ranging from 6 to 15 months, all 20 patients are biochemically cured. This study demonstrates that endoscopic parathyroid exploration can be performed via a lateral incision.     

Endoscopic surgery for a parathyroid functioning adenoma resection with the neck region-lifting method.

Recently, endoscopic surgery has been applied to cervical exploration. We have developed new techniques for endoscopic neck surgery. We reported on a 53-year-old Japanese man with functioning parathyroid adenoma resected by endoscopic surgery with a neck region-lifting method. A 10-mm midline trocar for the endoscope and two 5-mm lateral trocars were inserted from the anterior chest wall to avoid neck scars. There were no intraoperative complications. The incisions were completely covered by the patient's undergarments.     

Videoendoscopic approach for parathyroid adenomas: results of a prospective study of 100 patients]

STUDY AIM: The aim of this prospective study was to report the results of 100 consecutive video-endoscopic parathyroidectomies in patients suspected of having a single adenoma. PATIENTS AND METHOD: From March 1997 to September 2000, 80 females and 20 males (mean age: 49.5 years) were operated on. They were selected on the basis of the following criteria: preoperative imaging in favour of a single adenoma, absence of goiter and no prior neck dissection. The technique required three trocars; one 5 mm trocar inserted through the middle line of the neck for the 0-degree 5 mm endoscope, and two 3 mm trocars inserted laterally in order to perform a bilateral exploration. The neck was inflated to 10 mm Hg pressure with a low flow (3 L/min). RESULTS: Exploration was unilateral, bilateral and interrupted respectively in 52, 45 and 3% of the cases. The reasons for stopping were: an incidentally discovered thyroid carcinoma; moderate bleeding occurring from an anterior jugular vein after introduction of a lateral trocar; and a too-short neck. Parathyroid abnormalities were found in 86% of the patients (84 single adenomas, one double adenoma, one hyperplasia of the four glands). In 14% of the cases, the exploration was unsuccessful. A horizontal cervicotomy was required in 15% of the cases (14 negative explorations and one hyperplasia of the four glands). No intraoperative or postoperative complications occurred. The mean hospital stay was 24 hours. After 3-month follow-up, the serum calcium level was normal in 96% of the cases and cosmetic results were excellent. CONCLUSION: A video-endoscopic approach for parathyroidectomy is feasible and safe. With sufficient experience, a bilateral and complete exploration of the neck is possible. Therefore this technique represents a good alternative to the traditional cervicotomy in patients with uniglandular disease.     

Port-site metastases

Background: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO₂ along trocars (chimney effect) in the development of port-site metastases. Methods: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO₂ was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO₂ along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. Results: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p= 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p= 0.009). Conclusion: Tissue trauma at trocar sites and leakage of CO₂ along a trocar appear to promote implantation and growth of tumor cells at port sites. Received: 15 May 1997/Accepted: 3 March 1998     

Endoscopically assisted, minimally invasive parathyroidectomy

BACKGROUND: Despite the success of open parathyroid exploration, minimally invasive alternatives have been emerging. This study reports an experience with endoscopically assisted, minimally invasive parathyroidectomy and evaluates its current role in patients undergoing surgery for hyperparathyroidism. METHODS: One hundred consecutive patients requiring surgery for hyperparathyroidism were evaluated. Endoscopic parathyroidectomy was offered based on the absence of coexisting nodular thyroid disease, previous neck surgery or irradiation, suspicion of parathyroid hyperplasia, or other anatomical or medical contraindications. Some 24 of 100 patients fulfilled the criteria and underwent endoscopic parathyroidectomy. Unequivocal localization to a single site by a technetium-99m-radiolabelled sestamibi scan allowed removal of the adenoma through a 25-mm suprasternal incision while being guided by a surgical telescope. RESULTS: There were no statistically significant differences in operating time or the mean size of resected adenomas between patients undergoing endoscopic and open parathyroidectomy. Four patients required conversion to an open procedure. Two patients developed temporary recurrent laryngeal nerve paresis and one had persistent hyperparathyroidism. CONCLUSION: Although endoscopic parathyroidectomy is technically feasible, its applicability is limited to a minority of patients undergoing operation for hyperparathyroidism. The potential for higher complication and failure rates makes optimism for the procedure appropriately guarded.     

Multiple-gland disease in primary hyperparathyroidism: a function of operative approach?

HYPOTHESIS: The approach to surgery for primary hyperparathyroidism (PHPT) is controversial. To determine whether routine bilateral neck exploration increases the detection of multiple-gland disease compared with a focused unilateral approach, we compared the incidence of single vs multiple-gland disease in patients undergoing surgical treatment for PHPT as a function of unilateral or bilateral exploration. DATA SOURCES: From 1993 through 1997, 214 consecutive patients underwent initial bilateral neck exploration for PHPT by a single surgeon. Each patient underwent the surgical procedure without prior localizing studies. Four parathyroid glands were identified, and abnormal glands were excised. The results were compared with published studies of patients who underwent either bilateral neck exploration or focused unilateral neck exploration for PHPT. STUDY SELECTION: All reported studies from 1995 through 2001 in a MEDLINE search using the terms "parathyroidectomy" or "primary hyperparathyroidism and surgery" and either "bilateral" or "conventional" or "minimally invasive," "selective," or "unilateral." DATA EXTRACTION: The studies were analyzed for numbers of patients and a final diagnosis of either a single adenoma or multiple-gland disease (double adenoma or hyperplasia). Proportions were compared statistically with a chi(2) test. DATA SYNTHESIS: In our series of 214 patients who underwent bilateral neck exploration, 79.4% had a single adenoma, and 20.6% had multiple-gland disease. Of 2166 patients in 14 studies who underwent bilateral neck exploration, 79.7% had a single adenoma, and 19.3% had multiple-gland disease. Of 2095 patients in 31 studies with a focused unilateral approach, 92.5% had a single adenoma, whereas only 5.3% had multiple-gland disease. The incidence of multiple-gland disease was significantly lower among patients treated with a focused unilateral approach compared with a bilateral approach as used in our series and the literature (P<.001). CONCLUSION: The data suggest that a focused unilateral surgical approach for PHPT may underestimate the incidence of multiple-gland disease.     

Incarcerated hernia in 11-mm nonbladed trocar site following laparoscopic appendectomy

Background:

Nonbladed trocars are considered less traumatic to the abdominal wall due to the lack of fascial incision. It has been suggested that closure of the abdominal fascia may be unnecessary when such nonbladed trocars are used.

Case Report:

We report on 2 patients who were diagnosed with trocar-site hernias 2 days after laparoscopic appendectomy performed using 11-mm nonbladed trocars.

Conclusion:

Although rare, trocar-site hernias after laparoscopic surgery with nonbladed trocars remain a cause of postoperative morbidity and require prompt intervention. Therefore, this report underscores the significance of performing meticulous closure of all trocar sites that are ≥10mm.     

Endoscopic Parathyroidectomy: Why and When?

BACKGROUND: In recent years, several new minimally invasive techniques for parathyroidectomy (MIP) have been developed. There was a rapid worldwide acceptance of mini-open procedures by most surgeons. However, the use of an endoscope remains debatable. This study was designed to determine the role of preoperative imaging studies in the decision-making for using an endoscope during MIP. METHODS: All patients with sporadic primary hyperparathyroidism (PHPT) and candidate for MIP underwent localizing studies. MIP was proposed only for patients in whom a single adenoma was localized by both ultrasonography and sestamibi scanning. Three locations were described: (1) posterior to the two superior thirds of the thyroid lobe; (2) at the level of or below the inferior pole of the thyroid lobe but in a plane posterior to it; (3) at the level of or below the tip of the inferior pole of the thyroid lobe but in a superficial plane. In locations 1 and 2, the nerve was considered to be at risk and an endoscopic lateral approach was indicated. In location 3, a mini-open approach was indicated. RESULTS: Of the 165 patients operated on for PHPT in 2006, 86 underwent MIP. According to the results of imaging studies, 39 patients presented an adenoma in location 1, 21 in location 2, and 26 in location 3. In locations 1 and 2, 59 patients (1 false-positive) had an adenoma that was located posteriorly, in close proximity to the nerve; all were cured. In location 3, 25 patients (1 false-positive) presented an inferior parathyroid adenoma superficially located; all were cured. There was no transient or permanent laryngeal nerve palsy. CONCLUSIONS: In patients who are candidates for MIP, we recommend the use of the endoscope for the resection of parathyroid adenomas that are located deeply in the neck.     

Tip for microlaparoscopic cholecystectomy: easy removal of the gallbladder after laparoscopic cholecystectomy using the three-port technique

The standard laparoscopic cholecystectomy usually requires four trocars: two 10-mm and two 5-mm trocars. With the development of mini-instruments, laparoscopic surgeons have developed the two- or three-port techniques. The selection of the number and size of trocars depends on the surgeon's experience and preferences. Removal of the gallbladder is critical in the mini-instrument technique. To remove the gallbladder through the umbilical port, a 5-mm telescope should be inserted through one of the 5-mm ports, or one of the 5-mm trocars should be replaced with an 11-mm trocar by extending the incision. A simple and easy technique was applied to retrieve the gallbladder without changing the telescope or extending the skin incision for the trocar port to 11 mm. When the gallbladder is detached from the liver, the surgeon grasps the neck of the gallbladder via the 5-mm trocar and positions the gallbladder in the 11-mm trocar. While the surgeon keeps the gallbladder in the 11-mm trocar with the grasper held tangentially, the assistant removes the telescope and inserts a straight-toothed grasper to capture the gallbladder neck blindly. Subsequently, the removal of the gallbladder together with the trocar follows the usual technique. We have applied this technique to all our patients with limited or no inflammation of the gallbladder.     

Laparoscopic transgastric endoscopy after Roux-en-Y gastric bypass.

BACKGROUND: Access and endoscopic evaluation of the bypassed stomach is difficult after laparoscopic Roux-en-Y gastric bypass. We propose a minimally invasive technique to access the bypassed stomach after Roux-en-Y gastric bypass for endoscopic diagnosis and treatment. METHODS: First, we established carbon dioxide pneumoperitoneum to a pressure of 12-15 mm Hg. Next, 12-mm umbilical, 5-mm right upper quadrant, 5-mm left lower quadrant, and 15-mm left upper quadrant trocars were placed. A purse-string suture was placed on the anterior wall of the stomach. A gastrotomy was made using ultrasonic shears and the 15-mm trocar was placed into the stomach. The endoscope was then inserted through the 15-mm trocar, and the pneumoperitoneum was decreased to 10 mm Hg. Once the evaluation was complete, the gastrotomy was closed with a running suture or linear stapler. RESULTS: Ten patients at our institution have undergone laparoscopic transgastric endoscopy. Five patients had biliary pathologic findings. Four of these patients underwent successful endoscopic retrograde cholangiopancreatography and papillotomy; the procedure in the fifth patient was unsuccessful because stone impaction at the ampulla. Three patients were evaluated for gastrointestinal bleeding. One was diagnosed with a duodenal gastrointestinal stromal tumor, one with a bleeding duodenal ulcer, requiring surgical exploration; and the third had negative endoscopy findings. Two patients evaluated for chronic abdominal pain had negative endoscopy findings. No complications developed. CONCLUSIONS: Laparoscopic transgastric endoscopy is a safe and minimally invasive approach for the evaluation of the gastric remnant, duodenum, and biliary tree in patients who have undergone Roux-en-Y gastric bypass.     

Endoscopic thyroid resection using cutaneous elevation in lieu of insufflation

Background. Laparoscopic surgery to resect cervical masses has gained increasing acceptance during the past decade. This report describes the authors' technique and experience using total video endoscopic surgery to resect thyroid masses. Methods. The video camera is introduced through a 12-mm trocar inserted via a 10-mm infraclavicular incision in the sternal line. This incision will be hidden by the patient's undergarments postoperatively. An incision for a 12-mm trocar is made in each axilla, with additional incisions in the anterior chest made as necessary for the endoscope and instruments. Excellent exposure is produced by elevating the skin with hooks rather than by using carbon dioxide insufflation. This method reduces the incidence of subcutaneous emphysema and pneumomediastinum. Results. Twenty-two thyroid lesions were resected using total video endoscopic surgery (adenoma, 13; cancer, 5; benign cyst, 3; and Graves' disease, 1). Procedures included thyroidectomy (12), thyroidectomy and isthmusectomy (4), and subtotal thyroidectomy (2). Subtotal cervical adenectomy was performed in 3 patients with papillary carcinoma. Cosmetic results were excellent. Conclusion. Endoscopic surgery of the neck is safe, minimally invasive, and produces excellent cosmetic results. However, it is in an early stage of development. Techniques have yet to be standardized, and specialized instruments are not available. The field is likely to mature as surgeons gain more experience.     

Endoscopic endocrine surgery in the neck

Background: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. Methods: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. Results: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. Conclusions: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery. Received: 3 April 1997/Accepted: 6 August 1997     

Endoscopic parathyroidectomy. Surgical technique in primary hyperparathyroidism

We report our experience and technique of endoscopic removal of parathyroid adenomas in case of primary hyperparathyroidism. Scintigraphy, MRI scan and cervical ultrasound enable exact diagnosis and therefore exact localisation and placement of the three 5 mm trocars for endoscopic operation. The placement of the optic and the function trocars depends on the localisation of the adenoma. The free room to work in is created between thyroid and neck muscles and supported by insufflated CO2 with a pressure of 12 mm Hg. After the adenoma is taken out through an incision above the jugulum. With this technique we operated upon 3 patients successfully. Benefits for the patients seem to be a less painful postoperative course with minimal blood loss because of the exact exploration of the adenoma with minimal invasion of the surrounding tissue.     

Technique and results of the retroperitoneoscopic adrenalectomy via a lumbar approach

Introduction: Since 1992, endoscopic techniques have been used increasingly in adrenal-gland surgery. In the present paper, the technique of the retroperitoneoscopic adrenalectomy via a lumbar approach is described. Methods: The patient is placed in a lateral decubitus position. In the first step, a dilatation trocar is introduced in the retroperitoneal space to create an artificial cavity. The dilatation trocar is replaced by a blocking trocar to close off the operating field. After insufflation of CO₂, two additional trocars are introduced in the area of the conventional flank incision. Adrenalectomy is performed via these ports. Once the adrenal gland is completely mobilized, it is inserted into a sterile plastic bag and removed through the 1.5-cm incision. Conclusion: The retroperitoneoscopic approach to the adrenal gland appears to be suitable for benign adrenal-gland tumors up to a size of 6 cm.     

Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

Background Quick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively). Methods Forty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and ⁹⁹Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands. Results There were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant (ns)]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group. Conclusions BE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.     

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.     

A new camera trocar for gasless endoscopic thyroid surgery

A commercially available camera trocar diminishes the working space because of its high profile and is not proof against blood stain. The authors designed a new camera trocar for gasless endoscopic thyroid surgery. The new trocar consists of a shaft for a 5-mm endoscope as well as a disc 18 mm in diameter and 2 mm thick. The trocar is inserted from an adjacent 3-cm working port, pushed out to an incision for a 5-mm endoscope, and placed with the shaft up and the disc down. Because of its disc, the trocar is designed to be proof against blood stain and to maintain more working space. The newly designed trocar might be very useful for gasless endoscopic thyroid surgery as well as other gasless surgical procedures.     

Video-assisted parathyroidectomy for primary hyperparathyroidism

Background: Recent advances have allowed the performance of parathyroidectomy as an endoscopic procedure. Carbon dioxide (CO2) insufflation can be used to create a working space in the anterior neck, but it has been associated with a number of complications. We have devised a skin-lifting method to overcome these problems. Methods: Eleven consecutive patients underwent video-assisted parathyroidectomy. Preoperative imaging revealed a solitary adenoma in all 11 cases. A 3-cm oblique incision was made below the clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted, video-assisted parathyroidectomy was performed. Results: Surgery required 186 ± 50 min. No conversions to conventional cervicotomy were needed. Levels of serum calcium and intact parathormone decreased significantly in all patients on postoperative day 1. Laryngeal recurrent nerve paresis and seroma were noted in one patient each. Conclusions: Our procedure eliminates any potential CO2 problems and offers the advantages of direct manipulation and improved cosmesis. Endoscopic parathyroidectomy should be considered a viable option for the surgical treatment of a solitary adenoma.     

Development of an ultrasonically activated trocar system

BACKGROUND: Although rare, visceral and vascular injuries related to the insertion of conventional laparoscopic trocars may have disastrous consequences. Most of these injuries are due to the high puncture force applied to the trocar. We present the results of an animal laboratory evaluation of a newly developed ultrasonically activated trocar. METHODS: A total of 40 punctures were made in four pigs with an average weight of 53 kg. An 11-mmHg pneumoperitoneum was created through a Veress needle. A 10-mm diameter trocar was inserted in the midline for a laparoscope. A series of five trocars were then inserted on each lateral wall under laparoscopic control. Twenty punctures were made with a conventional reusable 11-mm trocar (CT) whose tip was sharp and conical. Twenty punctures were made with an 11-mm ultrasonically activated trocar (UT), whose fequency was 23.5 KHz and amplitude 150 mm. The cutaneous incision was made large enough so that the skin did not interfere with the trocar insertion. The force applied to the trocar was measured with a push-pull gauge connected to a computer. The following data were recorded: maximal force applied to the trocar to obtain insertion of the tip through the abdominal wall, maximum abdominal pressure increase during trocar insertion, and time for abdominal penetration. RESULTS: The average time needed for trocar penetration was 12.8 s with CT and 4.5 s with UT (p < 0.001). The average maximal force was 6.8 kgF with CT and 0.4 kgF with UT (p < 0.001). The average abdominal pressure increase was 7.6 mmHg with CT and 0.8 mmHg with UT (p < 0.001). At 30 days, no necrosis was found. Pathological findings were similar in both groups. CONCLUSION: Ultrasonically activated trocars required less time and much less force to be inserted. This may be a breakthrough in the safety of trocar insertion.     

Minimally invasive approach to the cervical spine: a proposal

BACKGROUND and PURPOSE: During the last 3 years, a minimally invasive video-assisted approach for parathyroidectomy and thyroidectomy has been developed. Because of the good exposure of the cervical spine during these procedures, the authors decided to perform an anatomic-radiologic study in order to evaluate which cervical vertebrae could be reached by this minimally invasive approach. PATIENTS and METHODS: Three consenting patients, two undergoing minimally invasive parathyroidectomy and one a conventional operation for C4-C5 disc herniation, were selected for this study. The procedure was carried out through a single 1.5-cm central skin incision above the sternal notch. After opening of the cervical linea alba, dissection was performed under endoscopic vision, without using any CO2 insufflation or trocar. After exposure of the prevertebral fascia, an operative tube was introduced through the cervical incision in order to maintain the operative space without using conventional retractors. RESULTS: Through this operative tube, it was possible to introduce both a 5-mm (or 3-mm) endoscope and the surgical instruments. In our patients, we inserted a 1-mm metal probe to exactly localize during fluoroscopy the vertebrae reached by the dissection (C2-C7). CONCLUSIONS: This study shows the feasibility of an anterior minimally invasive approach to the cervical spine. Although the exact indications have to be verified, a video-assisted approach could add some advantages to the well-known benefits coming from the anterior approaches to the cervical spine, especially in terms of cosmetic results and postoperative course and recovery.