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.