Special Approaches and Situations in Parathyroid Surgery
Reoperative parathyroid surgery represents a great challenge, since dense scar tissue and distorted tissue planes often complicate intraoperative localization. Various protocols and ideas have been proposed to improve the treatment of patients who require reoperation. One proposal includes mandatory 99mTc-sestamibi scanning and cervical ultrasound before operation.84 The group from the Medical College of Wisconsin recommended that failure to localize the gland should then prompt sequential CT, MRI, and selective venous sampling until localization is achieved. This approach makes use of the best available knowledge to accurately localize the gland before operation both to improve outcomes and to avoid complications. Most groups have reported appropriate, safe, effective outcomes with an emphasis on accurate preoperative imaging and ioPTH use to ensure effective cure.144 Several authors have reported successful experiences with radioguided parathyroidectomy in the reoperative setting. Cure rates decreased as the number of previous neck operations increased, and cure was more likely with single- versus mutligland disease. In the reoperative setting, a group from the Mayo Clinic found that 99mTc-sestamibi scanning was more sensitive than cervical ultrasound (84% vs 68%), and ioPTH was 99% sensitive for prediction of cure.145 Hyperfunctioning parathyroid tissue in reoperative PHPT can be usually resected by a cervical incision. Medial approach is the standard approach for exploration, which attempts to use the operative planes explored during the patient’s initial surgery. Lateral approach, dissecting the plane between the strap muscles and the sternocleidomastoid muscle, allows avoidance of scarred tissue from previous exploration and allows posterior access to the thyroid bed. 56 Medial approach, however, allows for bilateral cervical exploration. Most mediastinal disease is accessible by a cervical approach because the culprit is either retroesophageal or intrathymic. Median sternotomy, partial sternal split, or video-assisted thoracic approach, however, may be required.57
Surgical management for parathyroid cancer
Intraoperatively, parathyroid carcinoma is a large,...