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Parathyroid gland surgery

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Journal Club March 2000 James French
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Page 1: Parathyroid gland surgery

Journal Club March 2000

James French

Page 2: Parathyroid gland surgery

Bilateral Oblique Approach to Parathyroid Glands

Philippee C. J. Chaffanjon et al

• Objective To propose a simple and minimally invasive approach to parathyroid surgery

• Method A report of 20 years experience of an alternative surgical technique for parathyroid surgery

Page 3: Parathyroid gland surgery

Introduction

• History: Usual approach is low transverse

cervical incision

• Alternate approach to recent interest in minimally invasive endoscopic techniques

Page 4: Parathyroid gland surgery

Operative technique

• Supine position• 2 symmetrical

incisions, 2cm above and medial SC joint

• Skin, superficial fascia and platysma are cut without elevation and the deep fascia incised along SCM

Page 5: Parathyroid gland surgery

Op technique

• Omohyoid muscle exposed

• IJV visible along with efferent nerves of ansa cervicalis

• Pretracheal fascia incised parallel to the carotid sheath

Page 6: Parathyroid gland surgery

Op technique

• Retractors are used to separate the sheath from the infrahyoid muscles. This may be restricted by the middle thyroid vein which can be ligated

• The visceral sheath is opened close to the thyroid gland and the medial retractor lifts the lobe to expose the posterior side

Page 7: Parathyroid gland surgery

Op technique• The inferior thyroid artery

x’s the background and can be dissected out to help expose the recurrent laryngeal nerve

• It is possible to explore the arterial pedicles, thymus, and oesophagus with traction and counter traction using the retractors

Page 8: Parathyroid gland surgery

Method and Material

• Cases between 1976-1997

• 430 patients with primary hyperparathyroidism

• 167 patients with secondary or tertiary hyperparathyroidism

• Bilateral suction drainage was used for 10 years

• Selective draining for next 10 years

Page 9: Parathyroid gland surgery

Results

• Mean operating time 62 mins for 10

• 87mins for 20

• Drainage in 26.3% of cases

• Mean post op stay 2.8 days

• 83% single adenomas• Double adenomas 3%• Hyperplasia in 14%• MEN 13%

Page 10: Parathyroid gland surgery

Morbidity and Mortality

Page 11: Parathyroid gland surgery

Discussion

• Use bilateral approach as no pre-operative imaging

• High rate of morbidity due to re-operation

• Allows access to unusual locations of parathyroid glands

• Able to perform a thyroid lobectomy if necessary

• Similar results as presented in the literature

• Cosmetically good result• Low rates of bleeding and

infection

Page 12: Parathyroid gland surgery

Discussion cont.

• Future thyroid surgery able to be performed though standard incision with out scarring

• Low RLN injury rate• Low ansa cervicalis

injury rate

• Avoids potential morbidity of subcutaneous emphysema of the cercvicoscopic approach

• Decrease pain

Page 13: Parathyroid gland surgery

Comments

• Not a randomised series comparing two techniques

• ? Retrospective ? Prospective audit

• ? Level of training of surgeons

• ? Number of surgeons performing the operation

• Inclusion/exclusion criteria

• ? Basis of claim for decreased pain

Page 14: Parathyroid gland surgery

Conclusion

• Some deficiencies in paper

• Large series

• Reports good results

• Technique worth considering


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