Minimally invasive surgery for hyperparathyroidism

Surgical removal of the abnormal parathyroid gland or glands is the best treatment for hyperparathyroidism. In some cases, patients have elevated parathyroid hormone levels and high calcium levels but no disease symptoms. In these cases, the need for parathyroid surgery is controversial. Some advocate close follow-up without treatment. Others recommend surgical treatment, because irreversible changes such as osteopenia, osteoporosis, and heart disease may be occurring slowly over time when there are high calcium levels. Parathyroid surgery is necessary to decrease disease symptoms and prevent long term, irreversible health consequences. 

Traditionally, parathyroid surgery involves a long incision across the front of the neck and exploration of the tissues on both sides of the neck to locate and evaluate all four parathyroid glands. While this is still necessary in some cases, intraoperative technology has enabled the development of minimally invasive parathyroid surgery.

The technique for localization and confirmation of the abnormal gland often allows for a very limited procedure that quickly and easily identifies the abnormal gland without the need for surgical exploration or the need to disturb the normal glands.

These localization techniques include the following:

• Preoperative sestamibi scans to localize the abnormal gland.
• Radioguided surgery that leads the surgeon directly to the abnormal gland.
• Intraoperative parathyroid hormone monitoring that confirms correction of the problem.

The procedure is also done with nerve integrity monitoring systems, an electronic surveillance system to protect the recurrent laryngeal nerve that controls the voice.

A sestamibi scan is a radiological image of the thyroid glands. This test is performed in the radiology department and involves taking a small amount of a radioactive solution. This solution is taken up by the abnormal parathyroid glands, allowing them to be seen on a scan. If this test is positive and clearly shows only one abnormal gland, minimally invasive parathyroid surgery is an option. 

Minimally invasive surgery is the term used to describe an operation done through a small incision. The incision in minimally invasive parathyroid surgery is only about one inch long or smaller. Through this incision, the surgeon will locate the abnormal parathyroid gland, remove it, and send it to the pathologist for diagnosis. A parathyroid hormone blood test will also be performed. If the pathologist diagnoses the gland as an adenoma (a benign tumor) and the parathyroid hormone levels return to normal, the surgeon will close the small incision, and the case will be finished. 

If the parathyroid hormone level does not return to normal, there is likely another abnormal parathyroid gland that did not show up on the sestamibi scan. In this case, the incision will probably need to be enlarged to allow the surgeon a better view of the tissues in order to locate and examine the other parathyroid glands.

Minimally invasive surgery offers the advantages of not only a smaller incision, but also decreased pain as well. Minimally invasive surgery can be done under local anesthesia rather than general anesthesia in selected patients. All surgeries have risks such as bleeding and infection. Parathyroid surgery, both minimally invasive and traditional, also carries the risk of damage to the nerves that control the vocal cords and the risk of permanent low calcium levels, requiring supplementation. These risks are minimalized with advanced technology.