Journal Club March 2000

James French

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

Introduction

• History: Usual approach is low transverse

cervical incision

• Alternate approach to recent interest in minimally invasive endoscopic techniques

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

Op technique

• Omohyoid muscle exposed

• IJV visible along with efferent nerves of ansa cervicalis

• Pretracheal fascia incised parallel to the carotid sheath

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

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

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

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%

Morbidity and Mortality

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

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

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

Conclusion

• Some deficiencies in paper

• Large series

• Reports good results

• Technique worth considering