Direct, minimally invasive adenomectomy for primary hyperparathyroidism: An alternative to conventional neck exploration?

Abstract

Objective: To evaluate the feasibility and efficacy of a direct, minimally invasive adenomectomy (MIA) as an alternative to conventional neck exploration (CNE) in patients with primary hyperparathyroidism.

Summary background data: Because primary hyperparathyroidism is caused by a solitary adenoma in 85% to 90% of patients, a direct adenomectomy through a mini-incision would theoretically suffice whenever an adenoma is correctly localized on preoperative imaging. If effective, a less invasive method could spare the patient an unnecessary bilateral neck exploration, thus saving time and rendering future surgical procedures in the neck less problematic.

Methods: Between October 1994 and October 1998, 110 consecutive patients with biochemically proven primary hyperparathyroidism who were to undergo surgery were enrolled in this study. Ultrasound and spiral CT were routinely performed as standard preoperative imaging modalities in the first series of 65 patients. In the second series of 45 patients, ultrasound was performed as the sole initial modality; it was supplemented by CT only in case of inconclusive test results. If test results were unequivocal (one adenoma), the patient was offered MIA. CNE was performed if the results were equivocal or if multiglandular disease was suspected.

Results: Overall, 84 patients were selected for MIA and 26 for CNE. In the first series, 2 MIA procedures (2/51) were converted to CNE because of negative perioperative findings. All 65 procedures resulted in normocalcemia. In the second series, all but five (4/33 MIAs, 1/12 CNEs) resulted in normocalcemia. A reexploration (CNE) was performed in three patients, resulting in normocalcemia after resection of a second or third adenoma. Two patients are still awaiting reexploration. In both series together, 78 of the 110 patients were successfully treated with MIA and spared CNE.

Conclusion: MIA is a safe and effective alternative to CNE that may replace CNE in approximately two thirds of all patients.

Figure 1. Cross-section images of spiral CT scanning (A) and corresponding schematic drawings (B,C) depicting the route used for the direct approach to a parathyroid adenoma. (B) Lateral retraction of the sternocleidomastoid muscle (SM). (C) Lateral retraction of SM plus the internal jugular vein (JV), along with medioventral retraction of the right lobe of the thyroid gland (T), allows direct approach (downward arrow) to a parathyroid adenoma (A). C, common carotid artery.