Results

Our experience consists of 282 patients who underwent minimally invasive video-assisted parathyroidectomy (MIVAP) from February 1997 to April 2002. They represented 76% of a total of 370 referred to our department in the same period for PHPT. Correct preoperative localization

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TABLE 50-1. MIVAP: Reasons tor Conversion ]

Reason

No. of Cases

Double adenoma

4

Intrathyroid adenoma

3

Parathyroid carcinoma

1

No qPTHa

1

Difficult dissection

2

Negative exploration

9

Total

20

MIVAP = minimally invasive video-assisted

parathyroidectomy ;

qPTHa = quick parathyroid hormone assay.

of the lesion was considered mandatory before performing MIVAP. This consisted of either an ultrasound examination or a double-phase Tc 99m sestamibi scan. In many cases, both imaging studies had already been performed before referral. The mean age of the patients was 56 ± 13 years (range, 20 to 87 years); there were 224 women (79.5%) and 58 men (20.5%). The mean operative time of the procedure was 39 ± 22 minutes (range, 10 to 180 minutes). Fifteen patients had a concurrent video-assisted thyroid resection for associated diseases (microfollicular nodule, small papillary cancer), including 11 thyroid lobectomies (8 ipsilateral and 3 contralateral) and 4 total thyroidectomies.

Conversion to traditional cervicotomy was required in 20 patients (7%) (Table 50-1). The reasons for conversion were multiglandular disease in 4 (double adenoma); intrathy-roid adenoma in 3; difficult dissection in 2; negative exploration in 9 (in 3 cases the adenoma was not found even after conversion); intraoperative suspicion of parathyroid carcinoma in 1 (confirmed by frozen section and thus treated with synchronous thyroid lobectomy); and inadequate intraoperative PTH assay in 1. The conversions for double adenoma and intrathyroid lesions occurred at the beginning of our experience, when we were concerned about the prolonging the operation. More recently, when a further adenoma (even contralateral) or intrathyroid adenoma was suspected, we always continued with the video-assisted technique to perform a bilateral exploration or even a thyroid lobectomy (if necessary).

The mean size of the removed adenoma was 1.8 cm in its largest diameter. The lesion was superior right in 20.5% of cases, superior left in 23.1%, inferior right in 23.8%, and inferior left in 32.6%.

Patients are usually discharged after careful evaluation overnight for clinical symptoms of hypocalcemia and for serum calcium measurement.

There were two permanent laryngeal nerve palsies (0.7%) (6 months after surgery). There was one case of postoperative bleeding (0.3%) from a displaced clip on a middle thyroid vein, which required a reoperation 2 hours after surgery. Transient hypocalcemia occurred in 10 patients (3.5%) (Table 50-2).

Five (1.7%) patients had persistent hyperparathyroidism. In three patients, the adenoma was not found at exploration even after conversion. These patients are being re-evaluated. In two patients, the persistence was due to a false-positive qPTHa. A second exploration revealed a second adenoma missed at the time of the first operation. Both missed second

TABLE 50-2. MIVAP: Complications

Complication

No. of Cases (%)

Laryngeal nerve palsy

2 (0.7)

Bleeding

1 (0.3)

Transient hypocalcemia

10(3.5)

MIVAP = minimally invasive video-assisted parathyroidectomy.

adenomas were at the opposite side of the first operation, and they were successfully treated again by the MIVAP approach.

In this series, six patients had previously undergone thyroid surgery and two patients had undergone a prior exploration for PHPT. We successfully used a lateral approach in these patients so as to avoid adhesions in the midline.

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