Experience with Endoscopic Parathyroidectomy by the Lateral Approach

We developed the technique for endoscopic parathyroidectomy by the use of a lateral approach on the line of the anterior border of the SCM in 1998.13 Since then, over the course of 5 years (1998 to 2002), we operated on 528 patients with PHPT.34 An endoscopic approach was proposed for patients with sporadic PHPT, without associated goiter and without previous neck surgery, in whom a single adenoma was localized by means of sonography and sestamibi scanning. The procedure was performed by a lateral approach with insufflation for patients with adenoma located deep in the neck and by a gasless midline approach for patients with adenoma located anteriorly. QPTH assay was used during the surgical procedures. Blood was drawn at the time of intubation, first skin incision, adenoma extraction, and 5 and 15 minutes after extirpation. The highest preexcision level of QPTH falling more than 50% was considered significant. Calcemia, phosphoremia, and PTH were systematically evaluated in patients on days 1 and 8,1 month, and 1 year after surgery. All patients underwent preoperative and postoperative investigations of vocal cord movements.

Of the 528 surgical patients, 228 (43%) had a conventional open approach and 300 (57%) an endoscopic technique. Patients who underwent an open approach had some contraindications to an endoscopic approach: a large multinodular goiter that needed an associated thyroidectomy in 99 cases, previous cervical surgery in 42 cases, suspicion of multiglan-dular disease in 25 cases, inconclusive localizing studies in 48 cases, and other reasons in 14 cases (Table 51-1).

Endoscopic parathyroidectomy was performed in 300 patients with sporadic PHPT, by a lateral approach in 282 cases and by a central approach in 17 cases. One patient underwent thoracoscopy for an adenoma located very low in the anterior mediastinum. Of the 17 patients who had a central approach, 2 had an associated lobar thyroidectomy. The median operative time recorded was 50 minutes, which was lowered to 41 minutes in the last 100 cases. Recurrent laryngeal nerves were identified in 94.6% of cases, as was the ipsilateral parathyroid gland in 63.8% of cases when a lateral approach was used.

We were obliged to perform 42 conversions (14%) to open conventional surgery (Table 51-2). Causes for conversion included nothing found after a 2-hour search (11 cases), difficulties of dissection or a large adenoma taking most of the working space (7 cases), false-positive imaging studies (11 cases), and inadequate fall of rapid PTH assay (13 cases). Interestingly, 10 of the 13 patients had a multiglan-dular disease during open conversion and 3 had a false-negative QPTH assay. Thus, multiglandular disease was not detected by preoperative imaging in 10 cases but, in all 10 cases, was correctly predicted by QPTH assay.

Postoperative morbidity included permanent recurrent laryngeal nerve damage in one patient, two hematomas in the SCM muscle, and five capsular tears. The capsular disruptions occurred during the dissection of large and fragile adenomas weighing on average 4200 mg. There was no mortality, and most patients were discharged without morbidity from the hospital the next day. Two patients were left with hypercalcemia; persistent PHPT is suspected in the first patient, and another cause of hypercalcemia is likely in the second patient. With a median follow-up of 20.5 months, 1 of 150 patients had recurrent hypercalcemia after removal of an adenoma, whereas for 15 months the patient had normal serum calcium levels.

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