Intraoperative Localization Methods

Intraoperative Ultrasonography

High-resolution intraoperative US may be useful once the peak of the learning curve has been reached and operating time can be reduced significantly. Kem and colleagues51 found it to be more effective than any other preoperative technique for intrathyroid or perithyroid glands. The benefit of the routine use of intraoperative US in reoperative parathyroid surgery has not been established .

Radio-Guided Parathyroid Surgery

Tc 99m sestamibi is the most common localization test in recurrent parathyroid disease. It is possible to use an intraoperative gamma probe to detect abnormal parathyroid tissue. This method permits minimally invasive surgery (including video-assisted parathyroidectomy). Some authors report excellent results113117; however, longer follow-up and more studies are necessary before this procedure can be applied routinely.

The problems of this approach are false-positive results (thyroid disease), cost, and longer operative time.

Intraoperative PTH

Determination of intraoperative PTH (IOPTH) may confirm the removal of the hyperfunctioning parathyroid tissue, thus reducing the operative time.118119 If the basal levels of IOPTH drop more than 50% 10 minutes after parathyroid resection, it is indicative of successful surgery. Irvin and coworkers120121 reported a sensitivity of 93% with this method. These results have been confirmed by others,40 but most patients had single adenomas. Perhaps, in persistent parathyroid hyperplasia or double adenomas, the interpretation of the results is more difficult. Occasionally, the IOPTH drop is less than 50%, especially if the initial basal iPTH levels are not very high. For these reasons, this method needs a careful interpretation by the surgeon, considering also the previous sestamibi imaging and the surgical findings.113

Injection of methylene blue or toluidine blue is of little value and is not used.

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