Virtual Neck Exploration for Parathyroid Adenomas A First Step Toward Minimally Invasive Image-Guided Surgery

Objective: To evaluate the performance of 3-dimensional (3D) virtual neck exploration (VNE) as a modality for preoperative localization of parathyroid adenomas in primary hyperparathyroidism and assess the feasibility of using augmented reality to guide parathyroidectomy as a step toward minimally invasive image-guided surgery. Design: Enhanced 3D rendering methods can be used to transform computed tomographic scan images into a model for 3D VNE. In addition to a standard imaging modality, 3D VNE was performed in all patients and used to preoperatively plan minimally invasive parathyroidectomy. All preoperative localization studies were analyzed for their sensitivity, specificity, positive predictive value, and negative predictive value for the correct side of the adenoma(s) (lateralization) and the correct quadrant of the neck (localization). The 3D VNE model was used to generate intraoperative augmented reality in 3 cases. Setting: Tertiary care center. Patients: A total of 114 consecutive patients with primary hyperparathyroidism were included from January 8, 2008, through July 26, 2011. Results: The accuracy of 3D VNE in lateralization and localization was 77.2% and 64.9%, respectively. Virtual neck exploration had superior sensitivity to ultrasonography (P<.001), sestamibi scanning (P=.07), and standard computed tomography (P<.001). Use of the 3D model for intraoperative augmented reality was feasible. Conclusions: 3-Dimensional VNE is an excellent tool in preoperative localization of parathyroid adenomas with sensitivity, specificity, and diagnostic accuracy commensurate with accepted first-line imaging modalities. The added value of 3D VNE includes enhanced preoperative planning and intraoperative augmented reality to enable less-invasive image-guided surgery. JAMA Surg. 2013; 148(3): 232-238. Published online November 19, 2012. doi: 10.1001/jamasurg.2013.739