Parathyroid Surgery - Continued

Minimally Invasive Parathyroid Surgery:

Minimally invasive parathyroid surgery has become increasingly popular in the hands of experienced parathyroid surgeons. In this type of surgical approach, unlike the conventional surgical approach, the surgical incision is about 2.5-3.0 centimeters long, as opposed to 5-6 centimeters. The incision is smaller and heals better, leaving a smaller and almost invisible scar. In addition, in minimally invasive parathyroid surgery (parathyroidectomy), the tissues are dissected to a lesser extent with fewer traumas to the surrounding tissues. In this technique, depending on the expertise and preference of the surgeon, either fiberoptic endoscopes and video cameras are used ("minimally invasive Video Assisted Parathyroid Surgery"), or special probes capable of detecting radionuclide levels (injected in the patient's blood circulation before the surgery starts) are utilized to find and locate the abnormal gland(s). The rate of cure and complications are about the same as conventional four gland bilateral exploration, but the length of surgery is generally shorter, thus exposing the patient to shorter anesthesia time. In selected cases, the patient can go home the day of surgery. Others may be kept at the hospital for overnight observation, to be discharged home the day after surgery.

Intraoperative Surgical Technology:

Due to the fact that 15-20% of patients with hyperparathyroidism have multiple diseased glands, either due to multiple adenomas or multiple gland hyperplasia, it is of utmost importance that the surgeon makes sure that all the abnormal glands are removed successfully by the time the wound is closed. While the most important modality is visual inspection by the experienced surgeon, there are other ancillary methods that help the surgeon in the operating room. In addition to a thorough inspection of the surgical field with the help of special magnifying surgical glasses, we utilize "intraoperative parathyroid hormone measurement". With this technique, prior to starting the surgery, a small venous blood sample is obtained from the patient and is sent to a special laboratory within the hospital to obtain an accurate measurement of the pre-operative level of the parathyroid hormone. This baseline level is then compared to a post-excision level measured from another blood sample obtained from the patient 10 minutes after the suspected tumor is removed, while the patient is still under anesthesia and prior to closure of the surgical wound. In the meantime, while waiting for the results of the second hormone measurement to become available (about 20 minutes), the removed specimen is submitted to the pathologist for the purpose of getting a "frozen section" (quick microscopic look). If the frozen section is consistent with an abnormally enlarged parathyroid gland, the level of the parathyroid hormone drops 50% from the baseline level, and if the hormone level after removal of the tumor(s) also falls within the normal range of parathyroid hormone, the operation is deemed successful. If however, those conditions are not met; further surgical search to complete the operation successfully is warranted. In revision surgery, which is performed following previous unsuccessful surgical attempts, or in previously operated necks for unrelated reasons (spine surgery, etc.), as well as in patients with difficult neck anatomy, we use intraoperative nerve monitoring technique, which allows us to safely locate the nerves to the voice box (laryngeal nerves) during the surgery in order to safeguard them against inadvertent surgical trauma and injury.

Surgical Risks & Complications:

Both the conventional and minimally invasive (minimal access) parathyroid surgeries are generally safe and successful in experienced hands. Less than one percent of patients undergoing these surgical procedures may experience temporary or permanent laryngeal nerve weakness or paralysis. Such injury to the nerve(s) may result in varying degrees of hoarseness, breathiness of voice or difficulty with swallowing. Inability to successfully locate and remove the tumor(s) on one hand (failure of surgery to cure), and excessive removal of healthy parathyroid tissue resulting in hypoparathyroidism (inadequately low level of hormone) on the other, are known complications of this surgery. Bleeding, wound infection, and damage to food pipe (esophagus) or windpipe (trachea) are amongst the rare complications associated with this operation. Risks of anesthesia, particularly in elderly patients with multiple underlying medical conditions, must be taken into consideration when selecting suitable candidates for surgery.

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