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Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
M Vix, HA Mercoli, S Tzedakis, J Marescaux
Surgical intervention
2 years ago
1096 views
119 likes
1 comment
08:28
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
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.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

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.
M Vix, D Mutter, J Marescaux
Surgical intervention
2 years ago
574 views
71 likes
0 comments
09:39
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
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.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

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.
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
M Vix, J D'Agostino, L Soler, J Marescaux
Surgical intervention
6 years ago
4858 views
6 likes
0 comments
05:46
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.
Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism
In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT).
Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.
M Vix, L Soler, J Marescaux
Surgical intervention
10 years ago
1517 views
29 likes
0 comments
04:46
Minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism
In recent years, the advances in preoperative localization studies, the availability of intraoperative parathyroid hormone (PTH) assay and the introduction of cervicoscopy revolutionized the surgical treatment of primary hyperparathyroidism (PHPT).
Minimally invasive video-assisted parathyroidectomy (MIVAP) is an efficacious and feasible procedure with the same complication rate as conventional surgery and has significant advantages in terms of cosmetic results, postoperative pain, recovery, and patient satisfaction. MIVAP should be considered a valid and validated option for the treatment of sporadic primary hyperparathyroidism, especially in case of a suspected single adenoma. This video demonstrates a minimally invasive approach for the excision of a right superior parathyroid adenoma in an inter-crico-thyroid position in a 65-year-old female patient.
Minimally invasive video-assisted right parathyroidectomy for hyperparathyroidism
This video demonstrates a minimally invasive approach to excision of a parathyroid adenoma. A mini-incision is placed transversely in the midline and the laparoscope provides a magnified image for dissection. Modified instruments from open surgery are used and all the parathyroid glands can potentially be accessed by this approach.
This is the case of a 48-year-old female patient who has complained for several years of bone and muscular pain. Systematic preoperative diagnostic work-up showed hypercalcemia (3.5 mmol/L), hypophosphatemia (0.70 mol/L) and increased PTH levels (180 picograms/mL).
A superior right parathyroid adenoma was suspected on cervical ultrasound.
A CT-scan was performed preoperatively and a superior left parathyroid adenoma was found.
MIBI scintigraphy evidenced an area of increased uptake consistent with this.
A 2 cm suprasternal incision is carried out and the left lateral thyroid lobe is approached. The inferior thyroid artery and the left recurrent nerve are identified. These two structures are the major landmarks to correctly identify the parathyroid adenoma, which is then completely dissected before the pedicle is ligated.
M Vix, J Marescaux
Surgical intervention
11 years ago
368 views
23 likes
0 comments
08:48
Minimally invasive video-assisted right parathyroidectomy for hyperparathyroidism
This video demonstrates a minimally invasive approach to excision of a parathyroid adenoma. A mini-incision is placed transversely in the midline and the laparoscope provides a magnified image for dissection. Modified instruments from open surgery are used and all the parathyroid glands can potentially be accessed by this approach.
This is the case of a 48-year-old female patient who has complained for several years of bone and muscular pain. Systematic preoperative diagnostic work-up showed hypercalcemia (3.5 mmol/L), hypophosphatemia (0.70 mol/L) and increased PTH levels (180 picograms/mL).
A superior right parathyroid adenoma was suspected on cervical ultrasound.
A CT-scan was performed preoperatively and a superior left parathyroid adenoma was found.
MIBI scintigraphy evidenced an area of increased uptake consistent with this.
A 2 cm suprasternal incision is carried out and the left lateral thyroid lobe is approached. The inferior thyroid artery and the left recurrent nerve are identified. These two structures are the major landmarks to correctly identify the parathyroid adenoma, which is then completely dissected before the pedicle is ligated.
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
M Vix, HA Mercoli, L Soler, J Marescaux
Surgical intervention
6 years ago
1317 views
17 likes
0 comments
06:14
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique
This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.
F Costantino, M Vix, J Marescaux
Surgical intervention
11 years ago
921 views
20 likes
0 comments
08:20
Minimally invasive video-assisted right parathyroidectomy: lateral approach, variation of Miccoli's technique
This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.
Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
JM Baste, M Dazza, C Peillon
Surgical intervention
5 years ago
1047 views
29 likes
0 comments
06:54
Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
Virtual reality applied to video-assisted left superior parathyroidectomy
This video demonstrates how virtual reality is applied to video-assisted left superior parathyroidectomy. The virtual reconstruction is done from a preoperative contrast CT scan. The anatomy is then recreated layer by layer starting from the skin to the bone. Every anatomical structure can be removed or added back, in order to visualize areas that are normally not easily accessible and therefore difficult to identify. The relation with the adjacent vascular structures, arteries and veins, can also be very precisely established. A two cm horizontal neck incision is made below the sternal notch. The surgeons demonstrates a careful dissection of the anterior and lateral aspect of the thyroid. This manoeuvre allows to easily reach the area that had been previously virtually reconstructed. Once the gland is freed from its attachment the vascular pedicle is identified, isolated and clipped.
J Marescaux, M Vix, L Soler
Surgical intervention
12 years ago
457 views
2 likes
0 comments
03:49
Virtual reality applied to video-assisted left superior parathyroidectomy
This video demonstrates how virtual reality is applied to video-assisted left superior parathyroidectomy. The virtual reconstruction is done from a preoperative contrast CT scan. The anatomy is then recreated layer by layer starting from the skin to the bone. Every anatomical structure can be removed or added back, in order to visualize areas that are normally not easily accessible and therefore difficult to identify. The relation with the adjacent vascular structures, arteries and veins, can also be very precisely established. A two cm horizontal neck incision is made below the sternal notch. The surgeons demonstrates a careful dissection of the anterior and lateral aspect of the thyroid. This manoeuvre allows to easily reach the area that had been previously virtually reconstructed. Once the gland is freed from its attachment the vascular pedicle is identified, isolated and clipped.