AM I SUITABLE FOR A MINIMALLY INVASIVE PARATHYROIDECTOMY?

 

Primary hyperparathyroidism is a condition which leads to calcium being leached from the bones and deposited throughout all the tissues in the body. It leads to loss of calcium in the bones (osteoporosis) as well as the effects of  increased calcium levels throughout  the rest of the body This affects the brain (fatigue, sleep disturbance, memory loss, loss of executive functioning), muscles (weakness and fibromyalgia), joints (pain and arthralgia) kidneys (renal stones), heart and blood vessels (hypertension and increased risk of heart attack) as well as the tissue fluids (increased thirst and urination). In 90% of cases, it is due to a small benign tumour about the size of a coffee bean in the neck adjacent the thyroid gland (a parathyroid adenoma). If this can be located with special scans, then it can be removed using minimally invasive parathyroidectomy.

 

 

Minimally invasive surgery is defined as a procedure using both a minimal incision and minimal tissue dissection, leading to a small scar, less pain, shorter hospital stay,  and reduced complications.  It does not refer specifically to the use of the endoscopic (endoscopic parathyroidectomy)  nor the use of the robot (robotic parathyroidectomy).  The preferred technique for minimally invasive parathyroidectomy nowadays in most major endocrine surgery centres worldwide is the “mini-incision” cervical approach using a small (2-3 cm) incision in a skin crease on the side of the neck, or a central skin crease high in the middle of the neck depending on where the adenoma is located. Using special thermal sealing instruments, the adenoma can then be removed directly through the mini-incision with minimal dissection. Endoscopic parathyroidectomy, popularized in Europe, places the incision in the notch above the breastbone or on the chest wall and requires significantly more dissection without any major advantage. Robotic parathyroidectomy, popularized in Korea,  requires a large incision in the armpit with major dissection, increased pain and  higher risk of complications – it is not minimally invasive surgery, rather major surgery just to avoid a visible incision in the neck.

 

 

Most patients with hyperparathyroidism are suitable for minimally invasive parathyroidectomy. All that is required is that an adenoma can be located with a special scan such as 4DCT parathyroid scan.  Minimally invasive parathyroidectomy DOES NOT require:

  • endoscopic surgery - just a different surgical technique popular in Europe

  • robotic surgery - major invasive surgery just to avoid a neck scar

  • radioguided surgery –a marketing gimmick used in some US centres which is simply not effective

  • local anaesthetic surgery –  a modern “twilight” general anaesthetic is  as safe,  allows a smaller incision and is much pleasant  than local

  • intra-operative PTH -  a technique popular in the US to test that the adenoma has been removed but not used in Australia as it doesn’t work when you really need it

 

 

Mini-incision minimally invasive parathyroidectomy was first described by Professor Delbridge in 1998, and is now the standard technique around Australia.  Recently the results of nearly 5,000 cses were published with a 98% long-term cure rate and complication rate less than 1%.  If an adenoma cannot be located and surgery is still advised, then the approach is to examine all four parathyroid glands through a small central mini-incision. The size of the scar is not much different to  a minimally invasive parathyroidectomy, just that dissection on both sides of the neck is required.