Generally, the ideal patient for minimally invasive parathyroidectomy is one with sporadic PHPT and a single, well-localized adenoma in a virgin neck. There is debate about the percentage of patients who are eligible for minimally invasive parathyroidectomy—this depends on the selection criteria used by the surgeon. In our experience, these criteria were modified by the experience acquired during the development of our technique and the continuing improvement of surgical instrumentation.

Contraindications may be absolute or relative. Absolute contraindications include the following:

• Large goiters

• Recurrent disease

• Extensive previous neck surgery

• Multiple endocrine neoplasia and familial PHPT

• Parathyroid carcinoma

Relative contraindications include the following:

• Adenomas larger than 3 cm (depending on their shape, even larger adenomas can be removed)

• Lack of preoperative localization (a bilateral exploration can be performed through a central incision)

• Neck surgery on the opposite side of the suspected adenoma (a lateral access can be used)

• Previous neck irradiation or small thyroid nodules (concurrent thyroidectomy is possible)

Careful selection of the patient is most important to achieve an excellent outcome and to keep the conversion rate low. Although these criteria are presumably shared by most surgeons performing minimally invasive parathyroidectomy, the percentage of patients eligible for this surgery has varied greatly, from as little as 25 %9 to as much as 66%.10

Conversion: When, Why?

As in many other fields of endoscopic surgery, converting to open surgery is sometimes necessary. In minimally invasive parathyroid surgery, it is due to both technical difficulty of the procedure and drawbacks that are peculiar to parathyroid surgery. Thyroid abnormalities can cause bleeding or difficult dissection. Suspicion of malignancy, intrathyroidal parathyroid adenoma, and prolonged exploration time are also reasons for conversion.

Although most minimally invasive procedures are targeted parathyroidectomies (identifying only the adenoma) that have been validated by qPTHa2'4 or postoperative scintigraphy,7 " we prefer a unilateral exploration (identifying both an adenoma and a normal gland), which is almost always possible when using the endoscope. Before elective conversion, at least one side of the neck should have been explored thoroughly. Then, if a lateral approach was used, one should convert to open operation; however, if a central approach was used, contralateral exploration is still possible by the endoscopic technique. We explore the contralateral side endoscopically only if the procedure has not taken too long (1 to 1.5 hours) and if preoperative localization studies were not definitive. In our experience, an open operation does not guarantee that the adenoma will be easily found. In three cases out of nine conversions in our series, the adenoma was still not found even after an extensive open exploration (see "Results").

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