Surgical Endoscopy

, Volume 31, Issue 11, pp 4832–4833 | Cite as

Primary hyperparathyroidism treated by transoral endoscopic parathyroidectomy vestibular approach (TOEPVA)

  • Thanyawat Sasanakietkul
  • Tobias CarlingEmail author



Bilateral open cervical exploration with identifying all parathyroid glands and removing one or more enlarged parathyroid tumor(s) was the standard of care in primary hyperparathyroidism (pHPT). With the introduction of preoperative imaging and intraoperative parathyroid hormone (IOPTH) measurements [1, 2], various minimally invasive parathyroidectomy approaches have been developed, both open and endoscopic [3, 4, 5, 6, 7, 8]. The most commonly used approach currently in the USA is the minimally invasive open parathyroidectomy (MIP), which can be performed in the ambulatory setting with excellent cure and minimal complication rates [9, 10, 11, 12]. However, the operation requires a cervical incision, with occasionally poor cosmesis. The transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) provides a novel “scarless” approach to parathyroid surgery.


The aim of the video is to provide detailed instruction of the TOEPVA in pHPT and how to interpret IOPTH measurements in this setting.


The TOEPVA uses three incisions in the vestibule of the oral cavity, using two 5-mm ports and one central 11-mm port. The subplatysmal space is enlarged by hydrodissection and manual dilation. The working space is enhanced by insufflation to 6 mmHg. With the adjunct of preoperative imaging and IOPTH measurements, the extent of the operation is tailored to achieve biochemical cure.


TOEPVA is feasible and safe and provides an excellent cosmetic outcome. It is a more direct approach than other remote endoscopic parathyroidectomy techniques. TOEPVA is an excellent option for select patients with pHPT wishing to avoid a neck incision.


Endoscopic NOTES Parathyroidectomy Parathyroid adenoma Primary hyperparathyroidism Scarless Transoral 



Dr. Robert Udelsman and Dr. Angkoon Anuwong are thanked for assisting with the transoral operations.

Compliance with ethical standards


Dr.Thanyawat Sasanakietkul and Dr.Tobias Carling declare that there is no conflict of interests or financial ties to disclose.

Supplementary material

Supplementary material 1 (WMV 157312 kb)


  1. 1.
    Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J et al (1996) Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism. World J Surg 20(7):835–839 (discussion 9–40) CrossRefPubMedGoogle Scholar
  2. 2.
    Haber RS, Kim CK, Inabnet WB (2002) Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99 m)technetium sestamibi scintigraphy. Clin Endocrinol (Oxf) 57(2):241–249CrossRefGoogle Scholar
  3. 3.
    Miccoli P, Bendinelli C, Conte M, Pinchera A, Marcocci C (1998) Endoscopic parathyroidectomy by a gasless approach. J Laparoendosc Adv Surg Tech Part A 8(4):189–194CrossRefGoogle Scholar
  4. 4.
    Henry JF, Sebag F, Tamagnini P, Forman C, Silaghi H (2004) Endoscopic parathyroid surgery: results of 365 consecutive procedures. World J Surg 28(12):1219–1223CrossRefPubMedGoogle Scholar
  5. 5.
    Ikeda Y, Takami H, Niimi M, Kan S, Sasaki Y, Takayama J (2002) Endoscopic thyroidectomy and parathyroidectomy by the axillary approach. A preliminary report. Surg Endosc 16(1):92–95CrossRefPubMedGoogle Scholar
  6. 6.
    Karakas E, Steinfeldt T, Gockel A, Westermann R, Bartsch DK (2011) Transoral parathyroid surgery–feasible! Surg Endosc 25(5):1703–1705CrossRefPubMedGoogle Scholar
  7. 7.
    Karakas E, Steinfeldt T, Gockel A, Schlosshauer T, Dietz C, Jager J et al (2011) Transoral thyroid and parathyroid surgery–development of a new transoral technique. Surgery 150(1):108–115CrossRefPubMedGoogle Scholar
  8. 8.
    Benhidjeb T, Witzel K, Stark M, Mann O (2011) Transoral thyroid and parathyroid surgery: still experimental! Surg Endosc 25(7):2411–2413CrossRefPubMedGoogle Scholar
  9. 9.
    Carling T, Donovan P, Rinder C, Udelsman R (2006) Minimally invasive parathyroidectomy using cervical block: reasons for conversion to general anesthesia. Arch Surg 141(4):401–404 (discussion 4) CrossRefPubMedGoogle Scholar
  10. 10.
    Carling T, Udelsman R (2008) Focused approach to parathyroidectomy. World J Surg 32(7):1512–1517CrossRefPubMedGoogle Scholar
  11. 11.
    Sosa JA, Udelsman R (2003) Minimally invasive parathyroidectomy. Surg Oncol 12(2):125–134CrossRefPubMedGoogle Scholar
  12. 12.
    Udelsman R, Lin Z, Donovan P (2011) The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg 253(3):585–591CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of Surgery, Section of Endocrine SurgeryYale University School of MedicineNew HavenUSA

Personalised recommendations