Endoscopic Parathyroidectomy

Since the first successful parathyroidectomy performed in 1925 by Felix Mandl of Vienna,1 bilateral exploration and four-gland exploration has been considered the traditional approach in patients with primary hyperparathyroidism (PHPT). Performed by an experienced surgeon, this procedure is certainly one of the most gratifying of all operations. The success rate is reported to be of more than 96% with a concomitantly negligible operative mortality and morbidity rate.2

Nevertheless, today the surgical management of PHPT is in transition. The development and improvement of pre- and intraoperative localization methods, the introduction of intraoperative quick parathormone (QPTH) assessment, and the minimally invasive surgery revolution are the main reasons that have pushed surgeons at least to investigate the feasibility of other parathyroid procedures.

Several new minimally invasive techniques for parathyroidectomy have been developed: the unilateral approach,3 5 radioguided surgery,6,7 mini-open invasive techniques (miniincision with or without local anesthesia),8"10 and video-assisted or fully endoscopic techniques.11"21 These techniques have two common threads: they all have a limited incision compared with the classic open transverse cervical incision, and the surgery is targeted to one specific parathyroid gland. In most cases, the exploration of other glands is not performed or is limited.

Minimally invasive techniques are particularly suitable for parathyroid surgery for several reasons: they are only ablative procedures that do not require any elaborate surgical reconstruction, most parathyroid tumors are small and benign, and reduction in the length of the scar to about 10 to 15 mm is appealing to many patients.

It has been demonstrated that endoscopic parathyroidectomy is a feasible surgical procedure. Curiously, the first endoscopic removal of enlarged parathyroid glands was not from the neck but from a major ectopic location in the mediastinum.22 The first case of an endoscopic parathyroidectomy in the neck was reported by Gagner in 1996.11 Since then, the application of endoscopic techniques for parathyroid surgery has become more and more widely reported.

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