Not all patients presenting with PHPT are candidates for this surgery. Contraindications are mainly due to a larger goiter,

FIGURE 51-1. Endoscopic parathyroidectomy by a lateral approach: trocar positions.

Clamp Insufflation on purse-string tube

Laparoscope being inserted into trocar A

previous surgery in the parathyroid vicinity, suspicious multiglandular disease, and equivocal preoperative localization studies. Depending upon the operator's experience and according to the specific technique utilized, these contraindications can become relative. The central approach appears to be the best one for cases in which a bilateral exploration is anticipated or localization is uncertain.

Occasionally, endoscopic parathyroidectomy by the lateral approach can be performed in patients who have previously undergone contralateral neck operation or tracheotomy. According to certain authors, more than 60% of patients with PTHP are candidates for video-assisted parathyroidectomy.26

The endoscopic dissection of large adenomas (>3 cm) can be difficult because the working area remains limited . With limited experience, some surgeons can encounter major difficulties that may lead to capsular rupture and local seeding of parathyroid adenomatous cells. When this happens, a conversion is recommended. Nevertheless, some large but elongated adenomas, especially if situated in the posterosuperior mediastinum, can be removed endoscopically. The pedicle can be easily dissected at the level of the inferior thyroid artery, and their shape is amenable to expeditious extraction.

Patients with suggested multiglandular disease are not eligible for these procedures. Endoscopic parathyroid procedures should be reserved for patients with sporadic PHPT. All endoscopic parathyroid surgeons consider that the adenoma should be clearly localized before the operation. Therefore, the surgeon is highly dependent upon the quality of preoperative imaging to make a judicious choice for an endoscopic approach. Once contraindications have been eliminated, all patients with sporadic primary PHPT are considered candidates for this procedure. The choice between approaches is dependent on the quality and adequate interpretation of preoperative imaging studies. If the cervical ultrasonography and the nuclear scan do not correlate with a unique lesion at the same site, a traditional open cervical transverse incision is preferable. However, if the lesion is unique and confirmed by both studies, an endoscopic approach can be proposed. Depending on a posterior or anterior location, one can choose a central or lateral approach (Fig. 51-2).

Absolute contraindications remain the presence of a carcinomatous parathyroid gland, voluminous goiter, or both, no matter the experience of the surgeon or type of endoscopic technique employed.

Finally, endoscopic thyroidectomy and parathyroidectomy can be performed at the same time through the midline, but these procedures are indicated for small suspicious thyroid nodules less than 2.5 cm in diameter associated with PHPT.

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