Minimally invasive parathyroidectomy - FAQ

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Frequently Asked Questions: Parathyroidectomy (MIP) - 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 the focused lateral mini-incision technique, which involves an incision length of 1.5-2.0 cm (about ¾ in). The operation is done under direct vision, without the use of a videoendoscope. In our opinion, this technique provides the most 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.

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. MIP is not appropriate for those cases.

Q: What type of anesthesia is used for MIP and why?
A: We use a combination of local anesthesia and short-acting general anesthesia, which maximizes patient comfort both during and after the operation (1). This does involve going to sleep and having a breathing tube placed at the start of surgery. Awakening from anesthesia after surgery is smooth and rapid. Because the area of the incision is pre-treated with a local anesthetic that lasts approximately 6 hours, most of our patients experience little or no pain.

A number of centers perform MIP using local anesthesia, usually in combination with sedative medications (2-4). This appears to be a acceptable alternative to general anesthesia, and Dr. Yeh has experience with this approach.

At our unit, we use general anesthesia rather than local anesthesia plus sedation (the latter is also termed monitored anesthetic care or MAC). We have several reasons for this:

• 10-15% of MIP operations initially performed using local anesthesia ultimately require conversion to general anesthesia (5, 6). The unplanned induction of general anesthesia in the middle of an operation is disruptive to the flow of surgery and does not conform to our safety standards. Also, the entire experience is uncomfortable for the patient.
• Oversedation and fire are uncommon but acknowledged risks of monitored anesthetic care (7). Fire may result from the use of electrical devices in the presence of supplemental oxygen, which is given to patients under sedation.
• Having an operation in the neck while awake gives many people a sense of claustrophobia. An operation so close to the face is difficult to tolerate in comparison to an operation on the hand, leg, or even abdomen.
• Modern general anesthesia is extremely safe. Anesthesiology has led the field of medicine in applying systematic, technology-driven quality improvement initiatives that address both mechanical and human errors. These methods, some of which derive from areas such as aviation and engineering, have resulted in major gains in patient safety (8).

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: No. 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).

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: Sometimes. Bleeding into the neck is a well-known complication of thyroid and parathyroid surgery, occurring after about 1% of operations. This has been demonstrated in numerous studies performed across the world (25-27). Bleeding into the neck is an emergency that requires immediate medical attention. In the case of bleeding, we would much prefer that the patient be in the hospital, where they can be treated, rather than being unreachably mired in Southern California traffic. Though we may be criticized for unnecessary caution in the remaining >99% of patients who have no such complication, safety remains our highest priority.

A select number of patients are given the option of same day discharge after a 4-6 hour period of close observation. The following criteria must be met:

• Good general health
• Residence within 30 minutes drive of UCLA Medical Center
• Operation completed before 12:00 noon
• Adequate social supports (family member able to stay at home with the patient for 24 hours after surgery)
• Biochemically mild disease (total calcium < 12.0 mg/dL)

Though same-day discharge may sound like an attractive option, many patients ultimately find staying in the hospital overnight preferable. This assures that our patients remain free of work, domestic, and childcare duties for at least a short period of time after surgery.

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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