Journal of Visceral Surgery (2013) 150, 403—406
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Surgical technique parathyroidectomy through a minimally invasive gland-centered localized approach for primary hyperparathyroidism A. Taieb , M. Seman , F. Menegaux , C. Trésallet ∗ Service de chirurgie générale, viscérale et endocrinienne, CHU Pitié-Salpêtrière, université Pierre-et-Marie-Curie (Paris VI), 47-83, boulevard de l’Hôpital, 75651 Paris, France
Introduction The classical surgical management of primary hyperparathyroidism (HPT1) consists of exploration and identification of all four parathyroid glands through a transverse low cervical incision. This approach allows effective treatment of not only single gland HPT1 but also the detection of multiple adenomas and diffuse parathyroid hyperplasia involving all four glands (about 10% of cases) [1]. The localized approach focusing on a single parathyroid gland was developed in order to reduce the operative morbidity associated with multi-gland exploration (hematoma, recurrent laryngeal nerve palsy), to decrease the duration of surgery and hospitalization, and to minimize the cosmetic impact of the cervical incision. In addition, it can be performed under local anesthesia in fragile patients [2]. This mini-invasive approach can be proposed for laboratory-proven HPT1 where there is no family history of endocrine disease, no associated thyroid disease, and a single well-defined parathyroid adenoma localized by at least two concordant imaging studies (ultrasonography, MIBI scintigraphy, CT scan) [3]. The effectiveness of the surgery can be confirmed by frozen section histopathologic examination of the resected specimen and by serial intraoperative measurement of serum parathormone (PTH) levels. A fall of at least 50% in the PTH level after removal of the parathyroid gland confirms excision of the pathologic gland [4].
∗
Corresponding author. E-mail address: [email protected] (C. Trésallet).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.013
404
1
A. Taieb et al.
Positioning and incision
The patient is positioned supine with the neck hyperextended. A transverse incision about 1.5 cm long is made on the side of the adenoma, two fingerbreadths above the sternal notch between the sternocleidomastoid muscle (SCM) and the infra-hyoid strap muscles. This incision is carried through the platysma muscle in the same line with the afterthought that it can easily be converted to a standard bilateral cervical incision if there is need to explore all four parathyroid glands. Local anesthetic is injected in each plane down to the platysma and then further anesthetic is injected as indicated by patient discomfort.
to the thyroid compartment 2 —Approach cutaneous incision
The transverse skin incision is made with the scalpel and the platysma is divided with electrocautery.
Surgical technique parathyroidectomy
3
405
Schema of the operative approach
The thyroid compartment is approached laterally passing between the SCM and the infra-hyoid strap muscles, with retraction by two Farabeuf retractors and dissection with a fine curved hemostat. The thyroid lobe is the first easilyidentifiable landmark; dissection should be carried down in direct contact with the thyroid gland to guarantee that the right plane has been reached. 1. Parathyroid gland; 2. Thyroid lobe; 3. Localized approach; 4. Median approach for bilateral four-gland exploration; 5. Sternohyoid muscle; 6. Sternocleidomastoid muscle; 7. Sternothyroid muscle; 8. Omohyoid muscle; 9. Recurrent laryngeal nerve.
Retraction of the anterior cervical 4 muscles and the thyroid gland
The SCM muscle and the infra-hyoid strap muscles are retracted to either side by two Farabeuf retractors. The deeper-situated jugular vein and carotid artery are then retracted laterally as the thyroid gland is retracted medially.
406
A. Taieb et al.
5
Localized exploration of the parathyroid gland
6
Parathyroidectomy
This approach allows identification of the recurrent laryngeal nerve and the esophagus. The pathologic parathyroid gland should be sought in the area identified by preoperative imaging studies: • the superior parathyroid gland (P4) lies posterior to the recurrent nerve and the thyroid lobe, usually above the level of the inferior thyroid artery, although it may slide posteriorly along the esophagus; • the inferior parathyroid gland (P3) usually lies anterior to the recurrent nerve at the level of the inferior pole of the thyroid gland (either anteriorly or posteriorly) or in the prolongation of the thyro-thymic ligament. If necessary, it is possible to pull up the thymic remnant by this approach. The recurrent laryngeal nerve should always be identified and dissected over several centimeters.
Once the pathologic parathyroid adenoma has been identified, it is grasped with a DeBakey forceps and then carefully dissected free (to avoid fragmentation), identifying its vascular pedicle. The pedicle is then clipped or ligated and divided. The clip can serve as a landmark if future explorations are required for persistence or recurrence of HPT1, or if reintervention is necessary. Frozen section and histopathologic examination can be performed if there is any doubt whether the resected mass is actually a parathyroid gland rather than a lymph node, thyroid nodule, or fatty tissue. Final hemostasis is confirmed; if the wound remains moist, a resorbable hemostatic patch may be placed in the operative cavity. No drainage is necessary. The platysma muscle is closed with resorbable 4-0 sutures. The skin is closed with a resorbable intradermal running suture or with biologic glue.
Postoperative course
References
This procedure can be performed as ambulatory surgery. The patient must be fully informed of the risks of late-developing hypocalcemia, whose symptoms may occur several days after surgery. Precautionary measures (scheduled measurements of serum calcium, a telephone number for emergency contact) and written instructions should be provided to the patient at the time of discharge. In conventional four-gland parathyroid exploration, the great majority of patients can be discharged on Day 1 after measurement of calcium and PTH levels, with a prescription for supplemental calcium to be taken preventively and without waiting for symptoms of hypocalcemia to develop.
[1] Munoz-Bongrand N, Bothereau H, Sarfati E. [Localization of parathyroid glands and strategy for resection for hyperparathyroidism]. J Chir (Paris) 2004;141:299—302. [2] Norman J, Chheda H, Farrell C. Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results. Am Surg 1998;64:391—5 [Discussion 395—396]. [3] Mihai R, Barczynski M, Iacobone M, Sitges-Serra A. Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations. Langenbecks Arch Surg 2009;394:785—98. [4] 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;126:1004—9 [Discussion 1009—1010].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Surgical technique parathyroidectomy through a minimally invasive gland-centered localized approach for primary hyperparathyroidism A. Taieb , M. Seman , F. Menegaux , C. Trésallet ∗ Service de chirurgie générale, viscérale et endocrinienne, CHU Pitié-Salpêtrière, université Pierre-et-Marie-Curie (Paris VI), 47-83, boulevard de l’Hôpital, 75651 Paris, France
Introduction The classical surgical management of primary hyperparathyroidism (HPT1) consists of exploration and identification of all four parathyroid glands through a transverse low cervical incision. This approach allows effective treatment of not only single gland HPT1 but also the detection of multiple adenomas and diffuse parathyroid hyperplasia involving all four glands (about 10% of cases) [1]. The localized approach focusing on a single parathyroid gland was developed in order to reduce the operative morbidity associated with multi-gland exploration (hematoma, recurrent laryngeal nerve palsy), to decrease the duration of surgery and hospitalization, and to minimize the cosmetic impact of the cervical incision. In addition, it can be performed under local anesthesia in fragile patients [2]. This mini-invasive approach can be proposed for laboratory-proven HPT1 where there is no family history of endocrine disease, no associated thyroid disease, and a single well-defined parathyroid adenoma localized by at least two concordant imaging studies (ultrasonography, MIBI scintigraphy, CT scan) [3]. The effectiveness of the surgery can be confirmed by frozen section histopathologic examination of the resected specimen and by serial intraoperative measurement of serum parathormone (PTH) levels. A fall of at least 50% in the PTH level after removal of the parathyroid gland confirms excision of the pathologic gland [4].
∗
Corresponding author. E-mail address: [email protected] (C. Trésallet).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.013
404
1
A. Taieb et al.
Positioning and incision
The patient is positioned supine with the neck hyperextended. A transverse incision about 1.5 cm long is made on the side of the adenoma, two fingerbreadths above the sternal notch between the sternocleidomastoid muscle (SCM) and the infra-hyoid strap muscles. This incision is carried through the platysma muscle in the same line with the afterthought that it can easily be converted to a standard bilateral cervical incision if there is need to explore all four parathyroid glands. Local anesthetic is injected in each plane down to the platysma and then further anesthetic is injected as indicated by patient discomfort.
to the thyroid compartment 2 —Approach cutaneous incision
The transverse skin incision is made with the scalpel and the platysma is divided with electrocautery.
Surgical technique parathyroidectomy
3
405
Schema of the operative approach
The thyroid compartment is approached laterally passing between the SCM and the infra-hyoid strap muscles, with retraction by two Farabeuf retractors and dissection with a fine curved hemostat. The thyroid lobe is the first easilyidentifiable landmark; dissection should be carried down in direct contact with the thyroid gland to guarantee that the right plane has been reached. 1. Parathyroid gland; 2. Thyroid lobe; 3. Localized approach; 4. Median approach for bilateral four-gland exploration; 5. Sternohyoid muscle; 6. Sternocleidomastoid muscle; 7. Sternothyroid muscle; 8. Omohyoid muscle; 9. Recurrent laryngeal nerve.
Retraction of the anterior cervical 4 muscles and the thyroid gland
The SCM muscle and the infra-hyoid strap muscles are retracted to either side by two Farabeuf retractors. The deeper-situated jugular vein and carotid artery are then retracted laterally as the thyroid gland is retracted medially.
406
A. Taieb et al.
5
Localized exploration of the parathyroid gland
6
Parathyroidectomy
This approach allows identification of the recurrent laryngeal nerve and the esophagus. The pathologic parathyroid gland should be sought in the area identified by preoperative imaging studies: • the superior parathyroid gland (P4) lies posterior to the recurrent nerve and the thyroid lobe, usually above the level of the inferior thyroid artery, although it may slide posteriorly along the esophagus; • the inferior parathyroid gland (P3) usually lies anterior to the recurrent nerve at the level of the inferior pole of the thyroid gland (either anteriorly or posteriorly) or in the prolongation of the thyro-thymic ligament. If necessary, it is possible to pull up the thymic remnant by this approach. The recurrent laryngeal nerve should always be identified and dissected over several centimeters.
Once the pathologic parathyroid adenoma has been identified, it is grasped with a DeBakey forceps and then carefully dissected free (to avoid fragmentation), identifying its vascular pedicle. The pedicle is then clipped or ligated and divided. The clip can serve as a landmark if future explorations are required for persistence or recurrence of HPT1, or if reintervention is necessary. Frozen section and histopathologic examination can be performed if there is any doubt whether the resected mass is actually a parathyroid gland rather than a lymph node, thyroid nodule, or fatty tissue. Final hemostasis is confirmed; if the wound remains moist, a resorbable hemostatic patch may be placed in the operative cavity. No drainage is necessary. The platysma muscle is closed with resorbable 4-0 sutures. The skin is closed with a resorbable intradermal running suture or with biologic glue.
Postoperative course
References
This procedure can be performed as ambulatory surgery. The patient must be fully informed of the risks of late-developing hypocalcemia, whose symptoms may occur several days after surgery. Precautionary measures (scheduled measurements of serum calcium, a telephone number for emergency contact) and written instructions should be provided to the patient at the time of discharge. In conventional four-gland parathyroid exploration, the great majority of patients can be discharged on Day 1 after measurement of calcium and PTH levels, with a prescription for supplemental calcium to be taken preventively and without waiting for symptoms of hypocalcemia to develop.
[1] Munoz-Bongrand N, Bothereau H, Sarfati E. [Localization of parathyroid glands and strategy for resection for hyperparathyroidism]. J Chir (Paris) 2004;141:299—302. [2] Norman J, Chheda H, Farrell C. Minimally invasive parathyroidectomy for primary hyperparathyroidism: decreasing operative time and potential complications while improving cosmetic results. Am Surg 1998;64:391—5 [Discussion 395—396]. [3] Mihai R, Barczynski M, Iacobone M, Sitges-Serra A. Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations. Langenbecks Arch Surg 2009;394:785—98. [4] 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;126:1004—9 [Discussion 1009—1010].
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
