Minimally Invasive Single Gland Parathyroid Exploration

Minimally invasive parathyroidectomy (MIP) is the preferred operative approach by many surgeons for sporadic primary hyperparathyroidism (PHPT). The general goals of MIP are to limit operative dissection, reduce incision length, and improve postoperative recovery. Perhaps one of the greatest benefits of MIP is the potential for reduced scarring of deeper tissues, which allows for future operations (if needed) to be safer and less difficult. The most imperative prerequisite to MIP is adequate preoperative localization by imaging to guide the operation. This can be accomplished with several different modalities, but institutional and regional accuracy should be considered in the development of preoperative localization protocols. Many surgeons feel that two different modalities with concordant results are necessary to proceed with MIP. Key preoperative elements for success include the following: biochemical proof of primary hyperparathyroidism, imaging that is highly suggestive of single gland disease with identification of parathyroid adenoma location, and access to an experienced parathyroid surgeon. A standard parathyroid nomenclature system offers a concise, reliable means of communicating the exact location of enlarged parathyroid glands; it can facilitate surgical planning and selection of approach. Surgeon-performed ultrasound, just before incision, can assist in choosing optimal incision location. Both front door and back door approaches can be used. Intraoperative parathyroid hormone (PTH) monitoring can help confirm cure after resection. The role of robotic surgery and other advanced technologies will continue to evolve and will open the door to even better methods of surgically curing this metabolic disease.