Minimally Invasive Parathyroidectomy

  • Tobias Carling
  • Robert Udelsman


Approximately 85% of patients with primary hyperparathyroidism (pHPT) harbor a single adenoma and are cured by excision of the incident gland. The remaining patients display double adenomas (3–5%) or four-gland hyperplasia (10–15%). Thus, with accurate preoperative localization, targeted surgery using unilateral neck exploration under regional or local anesthesia has been developed, evaluated over the past decade and has become the standard of care in an ever-increasing number of specialized centers. Unilateral surgery for pHPT was advocated in 1975, and the side to be explored was chosen based on palpation, esophageal imaging, venography, or arteriography. If both enlarged and normal gland were found on the initial side, then contralateral cervical exploration was obviated. Other authors advocated a similar approach, arguing that bilateral exploration increased the risk, cost, and morbidity of surgery for pHPT. The Lund University surgeons advocated unilateral parathyroidectomy, which they defined as removal of both an adenoma and ipsilateral normal parathyroid. The excised tissue was studied microscopically during surgery with Oil Red O, and the decision to stop the operation at this stage was based on demonstration of a reduction in intracytoplasmic fat droplets in the excised adenomatous parathyroid tissue. Both techniques would fail, however, in the setting of a double adenoma on the contralateral side and if the essentially “random” choice of which side to explore was incorrect. Today, minimally invasive parathyroidectomy (MIP) is performed after preoperative parathyroid localization usually with high-quality sestamibi scans, ultrasonograhpy, or four-dimensional parathyroid CT scans, often under cervical block anesthesia during which a focused exploration is performed, and the rapid intraoperative parathyroid hormone assay is employed to confirm an adequate resection.


Parathyroid Gland Recurrent Laryngeal Nerve Parathyroid Adenoma Minimally Invasive Parathyroidectomy Bilateral Neck Exploration 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Roth SI, Wang CA, Potts JT Jr (1975) The team approach to primary hyperparathyroidism. Hum Pathol 6:645–648PubMedCrossRefGoogle Scholar
  2. 2.
    Wang CA (1985) Surgical management of primary hyperparathyroidism. Curr Probl Surg 22:1–50PubMedCrossRefGoogle Scholar
  3. 3.
    Tibblin S, Bondeson AG, Ljungberg O (1982) Unilateral parathyroidectomy in hyperparathyroidism due to single adenoma. Ann Surg 195:245–252PubMedCrossRefGoogle Scholar
  4. 4.
    Udelsman R, Donovan PI, Sokoll LJ (2000) One hundred consecutive minimally invasive parathyroid explorations. Ann Surg 232:331–339PubMedCrossRefGoogle Scholar
  5. 5.
    Bilezikian J, Potts JJ, Fuleihan G-H, Kleerekoper M, Neer R et al (2002) Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Clin Endocrinol Metab 87:5353–5361PubMedCrossRefGoogle Scholar
  6. 6.
    Udelsman R, Pasieka JL, Sturgeon C, Young JE, Clark OH (2009) Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 94:366–372PubMedCrossRefGoogle Scholar
  7. 7.
    Bilezikian JP, Khan AA, Potts JT Jr (2009) Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab 94:335–339PubMedCrossRefGoogle Scholar
  8. 8.
    Khan AA, Bilezikian JP, Potts JT Jr (2009) The diagnosis and management of asymptomatic primary hyperparathyroidism revisited. J Clin Endocrinol Metab 94:333–334PubMedCrossRefGoogle Scholar
  9. 9.
    Silverberg SJ, Lewiecki EM, Mosekilde L, Peacock M, Rubin MR (2009) Presentation of asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 94:351–365PubMedCrossRefGoogle Scholar
  10. 10.
    Udelsman R, Donovan PI (2006) Remedial parathyroid surgery: changing trends in 130 consecutive cases. Ann Surg 244:471–479PubMedGoogle Scholar
  11. 11.
    Stalberg P, Carling T (2009) Familial parathyroid tumors: diagnosis and management. World J Surg 33:2234–2243PubMedCrossRefGoogle Scholar
  12. 12.
    Carling T, Udelsman R (2005) Parathyroid surgery in familial hyperparathyroid disorders. J Intern Med 257:27–37PubMedCrossRefGoogle Scholar
  13. 13.
    Carling T, Udelsman R (2003) Parathyroid tumors. Curr Treat Options Oncol 4:319–328PubMedCrossRefGoogle Scholar
  14. 14.
    Carling T, Udelsman R (2003) Advancements in the surgical treatment of primary hyperparathyroidism. Probl Gen Surg 20:31–37CrossRefGoogle Scholar
  15. 15.
    Lavely WC, Goetze S, Friedman KP, Leal JP, Zhang Z et al (2007) Comparison of SPECT/CT, SPECT, and planar imaging with single- and dual-phase 99mTc-sestamibi parathyroid scintigraphy. J Nucl Med 48:1084–1089PubMedCrossRefGoogle Scholar
  16. 16.
    Roach PJ, Schembri GP, Ho Shon IA, Bailey EA, Bailey DL (2006) SPECT/CT imaging using a spiral CT scanner for anatomical localization: impact on diagnostic accuracy and reporter confidence in clinical practice. Nucl Med Commun 27:977–987PubMedCrossRefGoogle Scholar
  17. 17.
    Mihai R, Simon D, Hellman P (2009) Imaging for primary hyperparathyroidism – an evidence-based analysis. Langenbecks Arch Surg 394:765–784PubMedCrossRefGoogle Scholar
  18. 18.
    Coakley AJ, Kettle AG, Wells CP, O’Doherty MJ, Collins RE (1989) 99Tcm sestamibi – a new agent for parathyroid imaging. Nucl Med Commun 10:791–794PubMedCrossRefGoogle Scholar
  19. 19.
    Hetrakul N, Civelek AC, Stagg CA, Udelsman R (2001) In vitro accumulation of technetium-99m-sestamibi in human parathyroid mitochondria. Surgery 130:1011–1018PubMedCrossRefGoogle Scholar
  20. 20.
    Mitchell BK, Cornelius EA, Zoghbi S, Murren JR, Ghoussoub R et al (1996) Mechanism of technetium 99m sestamibi parathyroid imaging and the possible role of p-glycoprotein. Surgery 120:1039–1045PubMedCrossRefGoogle Scholar
  21. 21.
    Chen H, Mack E, Starling JR (2005) A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg 242:375–380; discussion 380–383PubMedGoogle Scholar
  22. 22.
    Denham DW, Norman J (1998) Cost-effectiveness of preoperative sestamibi scan for primary hyperparathyroidism is dependent solely upon the surgeon’s choice of operative procedure. J Am Coll Surg 186:293–305PubMedCrossRefGoogle Scholar
  23. 23.
    Blanco I, Carril JM, Banzo I, Quirce R, Gutierrez C et al (1998) Double-phase Tc-99m sestamibi scintigraphy in the preoperative location of lesions causing hyperparathyroidism. Clin Nucl Med 23:291–297PubMedCrossRefGoogle Scholar
  24. 24.
    Johnston LB, Carroll MJ, Britton KE, Lowe DG, Shand W et al (1996) The accuracy of parathyroid gland localization in primary hyperparathyroidism using sestamibi radionuclide imaging. J Clin Endocrinol Metab 81:346–352PubMedCrossRefGoogle Scholar
  25. 25.
    Jones JM, Russell CF, Ferguson WR, Laird JD (2001) Pre-operative sestamibi-technetium subtraction scintigraphy in primary hyperparathyroidism: experience with 156 consecutive patients. Clin Radiol 56:556–559PubMedCrossRefGoogle Scholar
  26. 26.
    Casara D, Rubello D, Cauzzo C, Pelizzo MR (2002) 99mTc-MIBI radio-guided minimally invasive parathyroidectomy: experience with patients with normal thyroids and nodular goiters. Thyroid 12:53–61PubMedCrossRefGoogle Scholar
  27. 27.
    Kettle AG, O’Doherty MJ (2006) Parathyroid imaging: how good is it and how should it be done? Semin Nucl Med 36:206–211PubMedCrossRefGoogle Scholar
  28. 28.
    Barczynski M, Golkowski F, Konturek A, Buziak-Bereza M, Cichon S et al (2006) Technetium-99m-sestamibi subtraction scintigraphy vs. ultrasonography combined with a rapid parathyroid hormone assay in parathyroid aspirates in preoperative localization of parathyroid adenomas and in directing surgical approach. Clin Endocrinol (Oxf) 65:106–113CrossRefGoogle Scholar
  29. 29.
    Lo CY, Lang BH, Chan WF, Kung AW, Lam KS (2007) A prospective evaluation of preoperative localization by technetium-99m sestamibi scintigraphy and ultrasonography in primary hyperparathyroidism. Am J Surg 193:155–159PubMedCrossRefGoogle Scholar
  30. 30.
    Maser C, Donovan P, Santos F, Donabedian R, Rinder C et al (2006) Sonographically guided fine needle aspiration with rapid parathyroid hormone assay. Ann Surg Oncol 13:1690–1695PubMedCrossRefGoogle Scholar
  31. 31.
    Geatti O, Shapiro B, Orsolon PG, Proto G, Guerra UP et al (1994) Localization of parathyroid enlargement: experience with technetium-99m methoxyisobutylisonitrile and thallium-201 scintigraphy, ultrasonography and computed tomography. Eur J Nucl Med 21:17–22PubMedCrossRefGoogle Scholar
  32. 32.
    Berber E, Parikh RT, Ballem N, Garner CN, Milas M et al (2008) Factors contributing to negative parathyroid localization: an analysis of 1000 patients. Surgery 144:74–79PubMedCrossRefGoogle Scholar
  33. 33.
    Rodgers SE, Hunter GJ, Hamberg LM, Schellingerhout D, Doherty DB et al (2006) Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 140:932–940; discussion 940–941PubMedCrossRefGoogle Scholar
  34. 34.
    Starker L, Mahajan A, Björklund P, Sze G, Udelsman R et al (2010) 4D parathyroid CT as the initial localization study for patients with de novo primary hyperparathyroidism. Ann Surg Oncol 18:1723–1728PubMedCrossRefGoogle Scholar
  35. 35.
    Udelsman R, Aruny JE, Donovan PI, Sokoll LJ, Santos F et al (2003) Rapid parathyroid hormone analysis during venous localization. Ann Surg 237:714–719; discussion 719–721PubMedGoogle Scholar
  36. 36.
    Reidel MA, Schilling T, Graf S, Hinz U, Nawroth P et al (2006) Localization of hyperfunctioning parathyroid glands by selective venous sampling in reoperation for primary or secondary hyperparathyroidism. Surgery 140:907–913; discussion 913PubMedCrossRefGoogle Scholar
  37. 37.
    Sippel RS, Becker YT, Odorico JS, Springman SR, Chen H (2004) Does propofol anesthesia affect intraoperative parathyroid hormone levels? A randomized, prospective trial. Surgery 136:1138–1142PubMedCrossRefGoogle Scholar
  38. 38.
    Stojadinovic A, Shaha A, Orlikoff R, Nissan A, Kornak M et al (2002) Prospective functional voice assessment in patients undergoing thyroid surgery. Ann Surg 236:823–832PubMedCrossRefGoogle Scholar
  39. 39.
    Lo Gerfo P (1999) Bilateral neck exploration for parathyroidectomy under local anesthesia: a viable technique for patients with coexisting thyroid disease with or without sestamibi scanning. Surgery 126:1011–1014; discussion 1014–1015PubMedCrossRefGoogle Scholar
  40. 40.
    Carling T, Donovan P, Rinder C, Udelsman R (2006) Minimally invasive parathyroidectomy using cervical block: reasons for conversion to general anesthesia. Arch Surg 141:401–404; discussion 404PubMedCrossRefGoogle Scholar
  41. 41.
    Chapuis Y, Fulla Y, Icard P, Nonnemacher L (1990) Peroperative assay of active parathormone 1–84 in surgery of primary hyperparathyroidism. Presse Med 19:1461–1462PubMedGoogle Scholar
  42. 42.
    Irvin GL 3rd, Dembrow VD, Prudhomme DL (1991) Operative monitoring of parathyroid gland hyperfunction. Am J Surg 162:299–302PubMedCrossRefGoogle Scholar
  43. 43.
    Carling T, Udelsman R (2008) Focused approach to parathyroidectomy. World J Surg 32:1512–1517PubMedCrossRefGoogle Scholar
  44. 44.
    Haustein SV, Mack E, Starling JR, Chen H (2005) The role of intraoperative parathyroid hormone testing in patients with tertiary hyperparathyroidism after renal transplantation. Surgery 138:1066–1071; discussion 1071PubMedCrossRefGoogle Scholar
  45. 45.
    Gold JS, Donovan PI, Udelsman R (2006) Partial median sternotomy: an attractive approach to mediastinal parathyroid disease. World J Surg 30:1234–1239PubMedCrossRefGoogle Scholar
  46. 46.
    Jaskowiak N, Norton JA, Alexander HR, Doppman JL, Shawker T et al (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224:308–320; discussion 320–321PubMedCrossRefGoogle Scholar
  47. 47.
    Udelsman R, Lin Z, Donovan P (2011) The superiority of minimally invasive parathyroidectomy based on 1,650 consecutive patients with primary hyperparathyroidism. Ann Surg 253:585–591PubMedCrossRefGoogle Scholar
  48. 48.
    Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235:665–670PubMedCrossRefGoogle Scholar
  49. 49.
    Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J (2002) Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg 236:543–551PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of SurgeryYale University School of MedicineNew HavenUSA
  2. 2.Department of SurgeryYale University School of MedicineNew HavenUSA

Personalised recommendations