Parathyroidectomy steps for ADENOMA
Minimally Invasive Parathyroidectomy (MIP) with Dr. Larian
Dr. Babak Larian of the CENTER for Advanced Parathyroid Surgery specializes in Minimally Invasive Parathyroidectomy to treat hyperparathyroidism. It can be performed under local anesthetic in under 20 minutes through a small incision so that you can go home within an hour after the operation. As a parathyroid surgery expert, Dr. Larian always conducts an advanced 4 gland assessment in order to provide his patients with the highest cure rate.
In the 1990’s 4 gland assessment was done by looking at all 4 glands and doing a biopsy. However, this was fraught with problems because doing a biopsy was not always able to distinguish between a normal and over functional gland. Additionally, when there is one parathyroid adenoma (a benign tumor in the parathyroid gland) that is overworking, the remaining 3 glands go into a dormant stage and shrink and become smaller (Figures 1 & 2); looking for these smaller parathyroids and biopsying them can potentially injure them and ultimately lead to permanent hypoparathyroidism. So the modern version of 4 gland assessment is to remove the enlarged gland and then look at the physiologic function of the remaining 3 glands by checking how much PTH they are producing & putting into the blood stream; the only accurate way to test PTH levels is by checking the amount in the blood stream (Figures 2 & 3). This is called rapid intra-operative PTH testing. So after removal of one gland if the PTH level goes down by more then 50% in 10 minutes then the remaining glands are dormant. If the PTH does NOT go down by 50% then that means one or more of the remaining glands are abnormal and should be investigated. This is very important because it is estimated that up to 25% of people with HPT have more then one gland that are abnormal.
So without PTH testing, 75% or more of the people who have only one abnormal gland would have extensive bilateral surgery unnecessarily.
Surgical Steps
1. PTH level testing in pre-surgery unit while placing the IV
2. Patient comes into the operating room and lays flat on the bed
3. Intravenous sedative (through the IV) – patient falls asleep while breathing on their own (NO BREATHING TUBE NEEDED). This is an option, rarely patients choose to be fully awake
4. Local anesthetic given
5. Skin cleaned & sterilized
6. Surgery
A. Incision 1.5 to 2 cm (less than an inch)
B. Expose the sternohyoid muscle (covering the thyroid & trachea)
C. Separating away the thin muscles from over the thyroid (not cutting the muscle) on the side where scans showed the abnormal parathyroid gland
D. Find the recurrent laryngeal nerve (RLN) deep to the thyroid
E. Follow the RLN, and protect the nerve
F. Get a pre-excision PTH level in the blood. Dissect the abnormal parathyroid gland and separate from the thyroid, lymph nodes, and fatty tissue
G. Identify the blood vessel that feeds the abnormal parathyroid, clamp & close the vessel
H. Check another PTH level at 5, 10 & 15 minutes to make sure it goes down by more than 50% & stays low
I. Examine the area to make sure there is no bleeding from the small blood vessels
J. Bring the muscles over the thyroid together again
K. Suture the skin close in multiple layers with absorbable sutures that are under the surface
L. Place a steri-strip (medical grade tape) on the incision for added protection
M. Fully awaken the patient and go to recovery room
N. Remain in the recovery room until fully awake
O. Release to go home usually after an hour.
Average Operative Time Is Less Than 20 minutes
The quickness of minimally invasive parathyroid surgery does not only mean minimal anesthesia and avoidance of unnecessary dissection but little operative time as well. Using this technique, the average operative time is less 20 minutes, which can be compared to the standard parathyroid surgery that takes two hours or more. Thanks to the advantages of Minimally Invasive Parathyroidectomy, almost all patients are sent home within an hour or two of the operation. Most importantly, the complication rate is less than half compared to the standard option.
Low Calcium Levels After Surgery
When a person has hyperparathyroidism due to a parathyroid adenoma, the remaining normal parathyroid glands which have not had to work much will shrink (Figure 2. below). These glands will be working but producing very little PTH at first, and gradual improve for a few weeks until they become fully active (how much less the 3 remaining parathyroids are working can be checked during surgery by seeing how much the PTH level comes down after removing the parathyroid adenoma). This is usually temporary, generally lasting 3 weeks and can cause the blood calcium level to drop below normal (called hypocalcemia). During this time period after surgery we at the CENTER recommend our patients supplement with calcium, vitamin D and magnesium.
Symptoms of Hypocalcemia
- Numbness and tingling around the lips, in both of your hands or f ingertips, or soles of both of your feet.
- Muscle cramps that last
- Some patients experience a “crawling” sensation in the skin
- Rarely severe unusual headaches
These symptoms appear between 24 and 48 hours after surgery.
Hypocalcemia Prevention
Prior to the surgery we will give you specific instructions (table below) as to how much calcium and vitamin D replacement you will need to take after surgery. This is dependent on your pre surgery calcium levels and the number of glands that are diseased, as well as how much the PTH drops during surgery. Some may need just Citracal Petites pills if the drop in PTH is in the normal range. If the drop is dramatic and below normal levels due to parathyroid glands being in shock then the person may need Calcium & Rocalcitrol. Dr. Larian will let you know what is appropriate for you after surgery.
Hypocalcemia Symptom Treatment
Patients with calciums of less than 14 prior to surgery: at any point if symptoms develop, you should take 8 extra Citracal Petites pills and contact Dr. Larian ASAP.
After Surgery Blood Tests
(You will be given prescriptions for these tests) One month & 6 months after surgery: Calcium, PTH & Vitamin D Levels. And then yearly thereafter.
If you are considering minimally invasive parathyroidectomy, schedule a consultation with Dr. Larian or give us a call at 310.461.0300 today!