Minimally invasive endocrine surgery

Posted by e-Medical PPT Sunday, August 5, 2012
Primary Hyperparathyroidism
85 % - single adenoma
10% - multi gland disease, hyperplasia
4% - double adenoma
1% - parathyroid carcinoma

Diagnosis:
Hypercalcemia with inappropriate high PTH level
24 urine calcium (h/o kidney stone)
Bone density study (h/o osteoporosis)
Imaging has no role in making the Dx

Indication for surgery:
1) age < 50
2) no ability for appropriate follow-up
3) serum Ca > 1.0 mg/dL above normal
4) urine Ca > 400 mg/24 hr
5) 30% decrease in renal function
6) complication of pHPT: nephrocalcinosis, osteoporosis ( T score <   2.5 SD 2 L-spine, hip or wrist) or sever psychoneurologic disorder)

Surgery:Four gland exploration vs single gland-minimally invasive technique

Minimally invasive techniques:
Mid-neck focused approach
Back-door approach
Video-assisted parathyroidectomy
Total endoscopic approach

Advantages of minimally invasive technique:
Ambulatory surgery (decrease hospital stay & coast)
Local / regional anesthesia:
- avoid risk of general anesthesia,
- ability patient to talk during the surgery and assess
      r. laryngeal nerve function,
- quicker recovery
Small incision
No drains
Suture removed at the day of surgery right before d/c to home (skin glue)

Benefits of videO-assisted minimally invasive technique:
Better R. laryngeal nerve visualization and preservation
No cutaneous flap – decrease postoperative scaring
Faster healing with better cosmetic result
Less pain

Key Recommendations Regarding Diagnosis of Thyroid Nodules:
Palpable nodule or Thyroid incidenteloma by US
TSH level - normal or low (or high TSH with US suspicious features), cold on scintigraphy.
Only nodule > 1 cm should be evaluated (unless suspicious US findings or high-risk history)
FNA results:Inadequate, Malignant,Indeterminate,Benign

Minimally invasive thyroid surgery
Utilization of up-to-date knowledge and technology:
video-endoscopic surgery,
sutureless thyroid with LigaSure vessel-sealing systems ,
intra – operative nerve monitoring for r.laryngeal and external branch of the superior laryngeal nerve
Intraoperative flexible laryngoscopy for vocal cord evaluation before and after procedure
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