Minimally invasive parathyroidectomy - FAQ

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Frequently Asked Questions: Parathyroidectomy (MIP) - Parathyroid Surgery

Q: How many parathyroid operations do you perform?
A: The UCLA Endocrine Surgery team performs up to 8 parathyroid operations per day. High surgical volume contributes to our expertise, and we recruited another surgeon in 2010 in order to keep our waiting times short. We have held back from going beyond 8 operations per day for a number of reasons. First, we wanted to avoid any type of "assembly line" mentality. Along those lines, we want to give every patient and family the amount of personalized attention that they deserve. Indeed, getting to know our patients on a personal level is one of the most satisfying aspects of our work.

We also treat a large number of patients with thyroid disease. Thyroid surgery and parathyroid surgery share an overlapping skill set. Furthermore, it is rather common for people (especially women over 45) to have both thyroid and parathyroid disease, and so all patients we see are evaluated for both conditions. For example, several times per year we discover a thyroid cancer in patients who have come to see us for parathyroid surgery. Those patients can potentially have both diseases cured with a single operation. For this reason, we believe it is advisable for patients with parathyroid disease to seek treatment at endocrine surgery centers with expertise in both thyroid and parathyroid conditions.

Q: How many parathyroid glands are routinely inspected parathyroid surgery?
A: We generally inspect at least 2 glands, often all 4. There is no "one-size-fits-all" approach to parathyroid surgery. The finding of one abnormal/enlarged gland and at least one normal gland, paired with a definitive fall in the intraoperative parathyroid hormone (PTH) level, is sufficient to yield a cure rate of 99%. If the PTH level does not fall definitively, then 4 glands are inspected (see Stratgies and priorities in parathyroid surgery).

Q: What is the definition of minimally invasive parathyroidectomy (MIP)?
A: Focused exploration/removal of a single abnormal parathyroid gland, directed by pre-operative localizing studies, performed through an incision measuring 2.5 cm (1 in) or less.

Q: What surgical technique is used and why?
A: We use either a focused lateral mini-incision technique or a central mini-incision technique. An incision length of approximately 2.0 cm (about ¾ inch) is used regardless of the approach and regardless of how many parathyroid glands are examined. Sometimes, in large or obese people, the incision is slightly longer. The operation is done under direct vision, without the use of a videoendoscope. In our opinion, this technique provides direct access to the parathyroid glands, minimizes tissue injury, and has superior cosmetic results.

Q: Who is eligible for MIP at UCLA?
A: Almost everyone, i.e. 85-90% of patients with primary hyperparathyroidism. These figures are among the highest reported in the scientific literature. Though some surgeons claim to offer MIP to all patients, it is not clear that they share the same strict definition of MIP to which we adhere. We would like to note that the distinction between MIP and four-gland examination has become less important over time, due to several factors. Most important among these is the fact that, because of extensive experience, UCLA and other expert centers can perform four-gland examination through the same small incision that is used for the focused approach. What this means is that the number of glands examined (one for a focused approach, two for a unilateral approach, four for a bilateral approach) generally does not affect the incision length.

Q: Am I still eligible for MIP even though my parathyroid sestamibi scan is negative?
A: Often yes, for several reasons. Parathyroid sestamibi scans are known to be more accurate at specialty centers (80-90% sensitive) than at non-specialty centers (30-70% sensitive). In our experience, among patients with negative scans performed elsewhere, more than half end up having a positive scan when the study is repeated here at UCLA.

Eligibility for MIP - View larger image >>

Furthermore, our use of highly sensitive surgeon-performed ultrasound (See Surgeon-performed ultrasound) enables detection of the subset parathyroid adenomas that do not show up on other imaging studies. We have leveraged this fact to extend eligibility for MIP. In other words, we perform MIP on patients with either positive sestamibi scans or positive ultrasound scans. (See Figure: Eligibility for MIP)

Q: Why isn't everyone eligible for MIP?
In a small fraction (about 10%) of patients, all imaging studies are negative. Many of these patients will turn out to have multiple gland parathyroid disease. A focused or unilateral approach would not be appropriate in these cases. These patients would receive a four-gland examination through the same small incision.

Q: What type of anesthesia is used for MIP and why?
A: Patients are given their choice of either general anesthesia (going completely to sleep) or light sedation. The choice most often centers around patient preference, though patient-specific factors such as a history of claustrophobia, obesity, sleep apnea, gastro-esophageal reflux disease, or any language barrier may make general anesthesia a safer choice for some.

Q: Is the gamma probe used during surgery? Is the operation done with radio-guidance (MIRP)?
A: No. In the years 1999-2001, a flurry of reports emerged proclaiming the benefits of radio-guided parathyroid surgery (9-12). This was followed by a similar number of reports stating that radio-guidance was unnecessary (13-16). Most experts now agree that the gamma probe does not offer any significant advantages, and it has largely been abandoned (17, 18).

Q: Is recurrent laryngeal nerve monitoring/EMG used during surgery?
A: Generally not. Some surgeons utilize a recurrent laryngeal nerve monitor in an effort to reduce the likelihood of nerve injury. This heavily marketed device has been studied exhaustively, and no benefit has been demonstrated from its use (19-24). However, there may be a select group of challenging cases, for instance re-do operations, in which it may offer some advantage. At UCLA, the nerve monitor is used at the discretion of the operating surgeon.

Q: Can very large parathyroid adenomas be successfully removed using MIP?
A: Yes. Most parathyroid adenomas are oval shaped, so the incision only needs to be as long as the short axis of the adenoma. Some examples are shown here. For reference, the normal parathyroid weighs approximately 45 mg.

2.5 cm (5768 mg) parathyroid adenoma removed through a 2 cm incision. This 29 year old man had multiple kidney stones. View larger image >>	2.6 cm (1738 mg) parathyroid adenoma removed through a 2 cm incision. This 25 year old woman had multiple kidney stones. View larger image >>
2.5 cm (7810 mg) parathyroid adenoma removed through a 2 cm incision. This 43 year old man had kidney stones and osteoporosis. Larger image 1 >> | Larger image 2 >>

Q: Can all important vital structures be safely seen through a 2 cm incision during MIP?
A: Yes. It is obviously essential to protect the recurrent laryngeal nerve during MIP. The focused lateral mini-incision technique is known to be both safe and effective.

Recurrent laryngeal nerve (white linear structure) as seen under spotlight illumination during MIP. View larger image >>

Q: Can surgery be done on a “day only” or “same day” basis?
A: Usually. Same day discharge is a good option for generally healthy individuals with strong social and family supports. We routinely observe patients closely for 4 hours after surgery to ensure safe discharge. All patients have the option to stay overnight if they so desire. Patients who live alone are advised to stay overnight, and those with significant medical conditions involving the heart, lungs, liver, or kidneys do require inpatient hospitalization, again for safety reasons.

References

1. Kaufman E, Epstein JB, Gorsky M, Jackson DL, Kadari A. Preemptive analgesia and local anesthesia as a supplement to general anesthesia: a review. Anesth Prog. 2005;52(1):29-38.

2. Inabnet WB, Fulla Y, Richard B, Bonnichon P, Icard P, Chapuis Y. Unilateral neck exploration under local anesthesia: the approach of choice for asymptomatic primary hyperparathyroidism. Surgery. 1999;126(6):1004-9; discussion 1009-10.

3. Miccoli P, Barellini L, Monchik JM, Rago R, Berti PF. Randomized clinical trial comparing regional and general anaesthesia in minimally invasive video-assisted parathyroidectomy. Br J Surg. 2005;92(7):814-8.

4. Udelsman R, Donovan PI. Open minimally invasive parathyroid surgery. World J Surg. 2004;28(12):1224-6.

5. Carling T, Donovan P, Rinder C, Udelsman R. Minimally invasive parathyroidectomy using cervical block: reasons for conversion to general anesthesia. Arch Surg. 2006;141(4):401-4; discussion 404.

6. Monchik JM, Barellini L, Langer P, Kahya A. Minimally invasive parathyroid surgery in 103 patients with local/regional anesthesia, without exclusion criteria. Surgery. 2002;131(5):502-8.

7. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-34.

8. Gaba DM. Anaesthesiology as a model for patient safety in health care. Bmj. 2000;320(7237):785-8.

9. Casara D, Rubello D, Piotto A, Carretto E, Pelizzo MR. 99mTc-MIBI radioguided surgery for limited invasive parathyroidectomy. Tumori. 2000;86(4):370-1.

10. Costello D, Norman J. Minimally invasive radioguided parathyroidectomy. Surg Oncol Clin N Am. 1999;8(3):555-64.

11. Flynn MB, Bumpous JM, Schill K, McMasters KM. Minimally invasive radioguided parathyroidectomy. J Am Coll Surg. 2000;191(1):24-31.

12. Sullivan DP, Scharf SC, Komisar A. Intraoperative gamma probe localization of parathyroid adenomas. Laryngoscope. 2001;111(5):912-7.

13. Burkey SH, Van Heerden JA, Farley DR, Thompson GB, Grant CS, Curlee KJ. Will directed parathyroidectomy utilizing the gamma probe or intraoperative parathyroid hormone assay replace bilateral cervical exploration as the preferred operation for primary hyperparathyroidism? World J Surg. 2002;26(8):914-20.

14. Inabnet WB, 3rd, Kim CK, Haber RS, Lopchinsky RA. Radioguidance is not necessary during parathyroidectomy. Arch Surg. 2002;137(8):967-70.

15. Perrier ND, Ituarte PH, Morita E, et al. Parathyroid surgery: separating promise from reality. J Clin Endocrinol Metab. 2002;87(3):1024-9.

16. Saaristo RA, Salmi JJ, Koobi T, Turjanmaa V, Sand JA, Nordback IH. Intraoperative localization of parathyroid glands with gamma counter probe in primary hyperparathyroidism: a prospective study. J Am Coll Surg. 2002;195(1):19-22.

17. Duh QY. Presidential Address: Minimally invasive endocrine surgery--standard of treatment or hype? Surgery. 2003;134(6):849-57.

18. Palazzo FF, Delbridge LW. Minimal-access/minimally invasive parathyroidectomy for primary hyperparathyroidism. Surg Clin North Am. 2004;84(3):717-34.

19. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery. 2004;136(6):1310-22.

20. Duh QY. What's new in general surgery: endocrine surgery. J Am Coll Surg. 2005;201(5):746-53.

21. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240(1):9-17.

22. Robertson ML, Steward DL, Gluckman JL, Welge J. Continuous laryngeal nerve integrity monitoring during thyroidectomy: does it reduce risk of injury? Otolaryngol Head Neck Surg. 2004;131(5):596-600.

23. Witt RL. Recurrent laryngeal nerve electrophysiologic monitoring in thyroid surgery: the standard of care? J Voice. 2005;19(3):497-500.

24. Yarbrough DE, Thompson GB, Kasperbauer JL, Harper CM, Grant CS. Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery. Surgery. 2004;136(6):1107-15.

25. Carty SE. Prevention and management of complications in parathyroid surgery. Otolaryngol Clin North Am. 2004;37(4):897-907, xi.

26. Fewins J, Simpson CB, Miller FR. Complications of thyroid and parathyroid surgery. Otolaryngol Clin North Am. 2003;36(1):189-206, x.

27. Harding J, Sebag F, Sierra M, Palazzo FF, Henry JF. Thyroid surgery: postoperative hematoma-prevention and treatment. Langenbecks Arch Surg. 2006;391(3):169-73.

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