Minimally invasive parathyroidectomy is a superior technique and should be adopted for the majority of patients with sporadic primary hyperparathyroidism.

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ObjectiveTo review the outcomes of 100 consecutive minimally invasive parathyroid explorations. Summary Background DataMinimally invasive parathyroidectomy (MIP) has challenged the traditional approach of bilateral neck exploration for patients with primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single adenoma that when resected results in cure. It therefore appears logical to perform a directed approach to adenoma extirpation. MIP involves high-quality sestamibi images obtained with single photon emission computed tomography to localize enlarged parathyroid glands in three dimensions, limited exploration after surgeon-administered cervical block anesthesia, rapid intraoperative parathyroid hormone assay to confirm the adequacy of resection, and discharge within 1 to 3 hours of surgery. MethodsMIP was offered to 100 selected consecutive patients during an 18-month period beginning in March 1998. ResultsNinety-two cases were accomplished under cervical block anesthesia and 89 of these on an ambulatory basis. The cure rate was 100%, and there were no long-term complications. The mean hospital charge for MIP was less than 40% of that associated with traditional exploration. ConclusionsOutpatient MIP appears to be the procedure of choice for most patients with primary hyperparathyroidism.The first successful parathyroidectomy for primary hyperparathyroidism was performed by Felix Mandl in Vienna in 1925.1 The procedure was performed under local anesthesia, four parathyroid glands were identified, and an enlarged parathyroid gland was excised. The patient experienced cure with marked resolution of his symptoms and signs of hyperparathyroidism.2 Thereafter, it became the standard of care in most institutions to perform bilateral neck explorations for primary hyperparathyroidism. The results in large series demonstrate cure rates that exceed 95%, with complication rates in the range of 1% to 2%. 3Despite the admirable results obtained in selected series, a group of surgeons has questioned the need for bilateral neck explorations for all patients with primary hyperparathyroidism. 4,5 This is based on the fact that 85% to 90% of patients with primary hyperparathyroidism have a single parathyroid adenoma that when excised results in cure. Therefore, if one could determine before surgery where the abnormal parathyroid gland was, a directed operation would appear to be logical. Several recent innovations have made this concept increasingly attractive: the exquisitely accurate preoperative diagnosis of primary hyperparathyroidism that can be achieved by measuring intact serum parathyroid hormone (PTH) levels; high-quality sestamibi scans, especially when combined with single photon emission computed tomography (SPECT); the availability and practical use of the intraoperative PTH assay, which can demonstrate resolution of PTH hypersecretion at the time of surgery; a resurgence of interest in local or regional anesthetic techniques; and referring physician and patient interest in minimally i...

ObjectiveTo evaluate the clinical utility of frozen section in patients with follicular neoplasms of the thyroid in a randomized prospective trial. Summary Background DataThe finding of a follicular neoplasm on fine-needle aspiration prompts many surgeons to perform intraoperative frozen section during thyroid lobectomy. However, the focal distribution of key diagnostic features of malignancy contributes to a high rate of noninformative frozen sections. MethodsThe series comprised 68 consecutive patients with a solitary thyroid nodule in whom fine-needle aspiration showed a follicular neoplasm. Patients were excluded for bilateral or nodal disease, extrathyroidal extension, or a definitive fine-needle aspiration diagnosis. Final pathologic findings were compared with frozen sections, and cost analyses were performed. ResultsSixty-one patients met the inclusion criteria. Twenty-nine were randomized to the frozen-section group and 32 to the nonfrozen-section group. In the non-frozen-section group, one patient was excluded when gross examination of the specimen was suggestive of malignancy and a directed frozen section was diagnostic of follicular carcinoma. Frozen-section analysis rendered a definitive diagnosis of malignancy in 1 of 29 (3.4%) patients, who then underwent a one-stage total thyroidectomy. In the remaining 28 patients, frozen section showed a "follicular or Hü rthle cell neoplasm." Permanent histology demonstrated well-differentiated thyroid cancer in 6 of these 28 patients (21%). Of the 31 patients in the non-frozensection group, 3 (10%) showed well-differentiated thyroid carcinoma on permanent histology. Complications were limited to one transient unilateral vocal cord dysfunction. All but one patient had a 1-day hospital stay. There were no significant differences between the groups in surgical time or total hospital charges; however, the charge per informative frozen section was approximately $12,470.

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