In cases of removal of mediastinal parathyroid adenomas by thoracoscopy, the advantages to the patient are irrefutable. However, taking into account the excellent results of the traditional bilateral cervical exploration, the same advantages are more difficult to demonstrate for all cervical approaches. Two studies comparing conventional parathyroid surgery with endoscopic techniques have clearly shown a diminution of postoperative pain and better cosmetic results with

FIGURE 51-2. Algorithm for the surgical management of patients eligible for an endoscopic parathyroidectomy.

endoscopic techniques.27 28 MIVAP is also associated with a shorter operative time.27 Those results await confirmation by further randomized studies.

In our opinion, compared with other minimally invasive procedures performed without the endoscope, endoscopic techniques are safer. The endoscope provides a greater and better surgical image, with magnification of all anatomic structures. By direct vision through mini-incisions, it is probably more difficult to get an adequate view of structures, and it is our belief that optimal conditions for exploration are not met even if surgeons use frontal lamps and surgical loops.

According to the type of access, conversion to conventional parathyroidectomy is necessary in 8% to 15% of cases.26'29 30 Main causes for conversion include difficulties of dissection, false-positive results of imaging studies, and multiglandular disease not detected by preoperative imaging but correctly predicted by QPTH assay results. Therefore, as with other minimally invasive techniques, the availability of the QPTH assay is of utmost importance. The overall accuracy of intraoperative QPTH monitoring is reported to be 97%.31 This test may be especially useful when localization studies are less certain. The risk of multiglandularity is nearly zero when both studies are positive for the same lesion site. This has been found to be 3.6% when only one localization study is positive versus 31.6% when both are negative32; the less certain the localization studies, the more certain the need for QPTH assay.

In experienced hands, endoscopic parathyroid techniques are as safe as the standard open procedure. There is no mortality. The incidence of recurrent nerve palsy is very low, less than 1%. Once again, we think that the use of the endoscope allows the surgeon to perform a dissection as safely as in open surgery. The rate of transient hypocalcemia is reduced, between 2.5% and 3.2%.17 :27 Similar findings have been reported with other minimally invasive techniques.33 This may be the result of a less extensive dissection and the targeted removal of the adenoma.

Carbon dioxide insufflation may cause hypercarbia, respiratory acidosis, and subcutaneous emphysema.

Nevertheless, insufflation is harmless as long as the procedure is performed under low pressure.

Endoscopic procedures can be performed in less than 1 hour and the operating time improves dramatically after the first procedures. The operating time may be even shorter than that of conventional cervicotomy, but it must be kept in mind that it is a focused operation and not a bilateral exploration. Endoscopic procedures are better performed under general anesthesia. Trocars are badly tolerated by patients under local anesthesia. In addition, swallowing and spontaneous breathing present impediments when dissecting in such a small operative space. Therefore, as for the conventional operation, in most cases one night of hospitalization is necessary. Whether endoscopic techniques are actually less costly than conventional parathyroidectomy is questionable.27

After surgery, 95% to 100% of patients are normocal-cemic. However, it should be kept in mind that these excellent results have been obtained in a group of carefully selected patients; these patients are considered to present a sporadic PHPT with a solitary adenoma clearly localized by imaging studies. In addition, the risk of persistent PHPT is minimized by the use of intraoperative QPTH assessment.

The learning curve must be considered. First of all, one must emphasize the need for expertise in performing conventional open parathyroidectomy. Mentoring by a surgeon who has experience with endoscopic neck techniques is recommended. These new operations are technically more challenging than standard cervical exploration. They should be confined to tertiary care centers.

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