The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.
Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.
A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.
Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.
Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.
The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
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Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.