Minimally invasive parathyroid surgery in 103 patients with local/regional anesthesia, without exclusion criteria

Abstract

Background: Parathyroid surgery for sporadic primary hyperparathyroidism (pHPT) can be accomplished with local/regional anesthesia and intraoperative monitoring of intact parathyroid hormone without exclusion criteria through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision (MIPL) in a high proportion of patients.

Methods: One hundred thirty-one consecutive patients with pHPT were offered MIPL. One hundred three patients elected to have this procedure. Patients were not excluded because of inadequate localization, previous parathyroid surgery, or need for concomitant thyroid surgery. Preoperative localization with ultrasound and/or sestamibi-single photon emission computed tomography scan was done in all patients. Almost all patients had intraoperative monitoring of intact parathyroid hormone (IMPTH).

Results: MIPL was accomplished in 89 of these 103 patients (86.4%), but 14 required conversion to general anesthesia. The main reasons for conversion were concomitant thyroid surgery, no positive preoperative localization, and previous parathyroid surgery. This procedure was accomplished in 13 patients requiring a bilateral procedure, 5 patients requiring thyroid surgery, 4 patients with no positive preoperative localization, and in 3 patients with previous parathyroid surgery. The complications of MIPL were comparable to the traditional bilateral exploration with general anesthesia. No patient experienced permanent hypoparathyroidism or postoperative bleeding. Two patients had transient recurrent laryngeal nerve paresis, and surgery failed to correct hypercalcemia in 5 (4.9%) of the patients. There appears to be less need for antiemetic medication in the MIPL patients compared with patients who had general anesthesia.

Conclusions: Parathyroid surgery for sporadic pHPT can be accomplished through a 1.0- to 1.25-inch (2.5- to 3.2-cm) incision with local/regional anesthesia, without exclusion criteria. Accurate preoperative localization, particularly localization to the same site by both ultrasound and 99mTc-sestamibi scan, and IMPTH can limit the surgery to a unilateral approach. One should be cautious in proceeding with MIPL in patients with need for concomitant thyroid surgery, no preoperative localization, or previous parathyroid surgery.