Minimally invasive parathyroidectomy without intraoperative localization

Minimally invasive parathyroidectomy (MIP) is gaining popularity as an alte rnative to traditional bilateral exploration for patients with primary hype rparathyroidism. The success of MIP relies on the ability of preoperative a nd intraoperative localization studies to guide a directed exploration for resection of a diseased gland. We hypothesize that excellent results can be achieved with MIP when only technetium-99m sestamibi (MIBI) is used for lo calization. We conducted a prospective analysis of all patients presenting with a biochemical diagnosis of primary hyperparathyroidism between January 1997 and November 2000. Patients meeting inclusion criteria were given a c hoice of MIP and directed exploration versus traditional bilateral explorat ion. Fifty patients chose MIP. Three patients who chose MIP had a negative MIBI, which left 47 patients in the primary study group. The MIBI correctly identified a parathyroid adenoma in 42 patients (89.3%). In two other pati ents MIBI was inaccurate; however, directed exploration was successfully co nverted to a bilateral exploration. Overall 44 of 47 (93.6%) patients in th e study group were rendered normocalcemic after the initial operation. Thre e patients experienced persistent hypercalcemia and subsequently underwent successful bilateral exploration. Including those patients choosing a bilat eral exploration, a total of 59 positive MIBI scans were evaluated. There w ere 54 true positives (positive predictive value 91.5%), and if all patient s had chosen a MIP 94.9 per cent would have been successfully treated at th e initial operation. Mean operative time for MIP was 54.6 minutes, and in 3 2 patients (68.1%) MIP was performed with local anesthesia and sedation. Tw enty-six patients (53.3%) were discharged the same day of the procedure. Th ere were no significant complications in any group analyzed. We conclude th at MIP can be successfully performed on the basis of a positive MIBI scan. The present study highlighting many of the advantages of MIP questions the necessity of additional adjuncts such as intraoperative parathyroid hormone measurement and gamma -probe localization.