V

Figure 5-12. Mincing of parathyroid tissue to be autotransplanted.

Figure 5-13. Scenario of minimally invasive parathyroidectomy. A, This is a preoperative sestamibi scan with increased uptake in the left neck on posterior orientation, suggesting a left upper gland. B, An oblique view of a sestamibi scan at 20 minutes. Close scrutiny suggests increased uptake near the left lower lobe of the thyroid. C, Lidocaine is used as a local anesthetic for skin incisions in addition to intravenous sedation. D, A Geiger counter gamma probe machine. Auditory counts are used to localize adenoma as a "hot spot." E, Parathyroid adenoma being removed through a small incision. The thyroid lobe is being retracted medially. F, The gland is excised and probed. Ex vivo counts are measured. G, A 1.3 cm parathyroid adenoma is measured ex vivo. H, Parathyroid adenoma is bivalved. The parenchyma has a classic brownish-yellow appearance. I, After excision, the 3 cm incision is noted. An interrupted absorbable suture is used to reapproximate the anterior fascia. J, Three tubes are immediately sent to the chemistry laboratory. The tube on the left has 3 mL of blood drawn before adenoma excision and is labeled "pre." The tube in the middle has 3 mL of normal saline and aspirated cells from the adenoma. The tube on the right has 3 mL of blood drawn 10 minutes after parathyroid tumor excision and is labeled "post." K, The automated machine is in the chemistry laboratory. The three samples are processed and the results are available in 10 minutes. L, The screen of the automated machine shows the parathyroid hormone levels from each sample after each has been spun and processed. The pre-excision value of 511 pg/mL and postexcision value of 11.0 pg/mL are observed. The aspiration confirms parathyroid tissue as the values > 2,500 pg/mL. M, The patient's small incision is closed in the operating room while the blood samples are being processed. When a 50% drop is noted, the patient is taken to the recovery room.

Figure 5-13. Scenario of minimally invasive parathyroidectomy. A, This is a preoperative sestamibi scan with increased uptake in the left neck on posterior orientation, suggesting a left upper gland. B, An oblique view of a sestamibi scan at 20 minutes. Close scrutiny suggests increased uptake near the left lower lobe of the thyroid. C, Lidocaine is used as a local anesthetic for skin incisions in addition to intravenous sedation. D, A Geiger counter gamma probe machine. Auditory counts are used to localize adenoma as a "hot spot." E, Parathyroid adenoma being removed through a small incision. The thyroid lobe is being retracted medially. F, The gland is excised and probed. Ex vivo counts are measured. G, A 1.3 cm parathyroid adenoma is measured ex vivo. H, Parathyroid adenoma is bivalved. The parenchyma has a classic brownish-yellow appearance. I, After excision, the 3 cm incision is noted. An interrupted absorbable suture is used to reapproximate the anterior fascia. J, Three tubes are immediately sent to the chemistry laboratory. The tube on the left has 3 mL of blood drawn before adenoma excision and is labeled "pre." The tube in the middle has 3 mL of normal saline and aspirated cells from the adenoma. The tube on the right has 3 mL of blood drawn 10 minutes after parathyroid tumor excision and is labeled "post." K, The automated machine is in the chemistry laboratory. The three samples are processed and the results are available in 10 minutes. L, The screen of the automated machine shows the parathyroid hormone levels from each sample after each has been spun and processed. The pre-excision value of 511 pg/mL and postexcision value of 11.0 pg/mL are observed. The aspiration confirms parathyroid tissue as the values > 2,500 pg/mL. M, The patient's small incision is closed in the operating room while the blood samples are being processed. When a 50% drop is noted, the patient is taken to the recovery room.

Compared with BNE, UNE leads to reduced cost from lower operating room charges, less general anesthesia, and earlier discharge (23- to 24-hour inpatient observation versus discharge 2 to 3 hours after surgery, respectively). There is a higher risk of permanent RLN injury with BNE versus UNE.

MIP produces favorable cosmetic results for the patient and allows more favorable technical conditions should reoperation be necessary. Udelsman compared the outcomes of conventional versus MIP performed by a single surgeon on 656 patients.57 Sixty-one percent of procedures were performed using the standard technique of bilateral cervical exploration under general anesthesia and 39% underwent MIP. The success rate for all procedures combined was 98% without significant difference between the two techniques. The complication rates for standard surgery versus MIP were 3.0% and 1.2%, respectively. MIP was associated with nearly a 50% reduction in operating time, a sevenfold reduction in length of hospital stay, and nearly a 50% reduction in total hospital charges.

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