|Year : 2019 | Volume
| Issue : 2 | Page : 119-123
Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience
P R K Bhargav1, M Sabaretnam2, V Amar3, N Vimala Devi1
1 Department of Endocrine Surgery, Endocare Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
3 Department of Bariatric and Metabolic Surgery, Apollo Hospital, Hyderabad, Telangana, India
|Date of Submission||29-Dec-2017|
|Date of Acceptance||18-Mar-2018|
|Date of Web Publication||12-Mar-2019|
Dr. P R K Bhargav
Endocare Hospital, Vijayawada, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Primary hyperparathyroidism is one of the most common endocrine disorders requiring surgical parathyroidectomy for its definitive treatment. Surgical exploration is traditionally performed through conventional open neck approach. A wide range of minimal access and minimally invasive endoscopic techniques (gas less and with gas) have been attempted in the past two decades. In this context, we evaluated the feasibility and safety of an innovative transoral endoscopic parathyroidectomy (EP) technique, which represents a paradigm shift in transluminal endocrine surgery.
Materials and Methods: This is a prospective study conducted at a tertiary care Endocrine Surgery Department in South India between May 2016 and August 2017. We employed a novel transoral, lower vestibular route for EP. All the clinical, investigative, operative, pathological and post-operative data were collected from our prospectively filled database. Statistical analysis was performed with SPSS 20.0 version.
Operative Technique: Under inhalational general anaesthesia, access to the neck was obtained with 3 ports (central frenulotomy and two lateral port sites), dissected in subplatysmal plane and insufflated with 6 mm Hg CO2 for working space. Rest of surgical steps is similar to conventional open parathyroidectomy.
Results: Out of the 38 hyperparathyroidism cases operated during the study, 12 (32%) were operated by this technique. Mean operative time was 112 ± 15 min (95–160). The post-operative course was uneventful with no major morbidity, hypocalcemia or recurrent laryngeal nerve palsy. Cure and diagnosis were confirmed by >50% fall in intraoperative parathyroid hormone levels and histopathology (all were benign solitary adenomas).
Conclusions: Through this study, we opine that this novel transoral vestibular route parathyroidectomy is a feasibly applicable approach for primary sporadic hyperparathyroidism, especially with solitary benign adenomas.
Keywords: Endoscopy, hypercalcemia, hyperparathyroidism, parathyroidectomy, parathyroid hormone level
|How to cite this article:|
Bhargav P R, Sabaretnam M, Amar V, Devi N V. Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience. J Min Access Surg 2019;15:119-23
|How to cite this URL:|
Bhargav P R, Sabaretnam M, Amar V, Devi N V. Applicability of transoral endoscopic parathyroidectomy through vestibular route for primary sporadic hyperparathyroidism: A South Indian experience. J Min Access Surg [serial online] 2019 [cited 2019 Jul 16];15:119-23. Available from: http://www.journalofmas.com/text.asp?2019/15/2/119/231912
| ¤ Introduction|| |
In past three decades, minimal access and minimally invasive techniques have become routine part of surgical armamentarium. Although it was initially experimented in abdominal and gynaecological surgeries, minimal access endoscopic techniques have been attempted in diverse sub specialities by the turn of the 21st century. Similarly, thyroid and parathyroid diseases have not been an exclusion to these approaches. Many endoscopic parathyroidectomy (EP) and endoscopic thyroidectomy (ET) techniques ranging from totally endoscopic, video-assisted, focussed mini-incision, transaxillary and chest wall approaches have been reported.,,,,,, Hyperparathyroidism is one of the most common endocrine surgical disorders after thyroid disease. Surgical excision of the offending parathyroid lesion is the only curative option for primary hyperparathyroidism (PHPT). Although the open approach through low anterior neck incision is the most common approach employed till date, various endoscopic techniques and novel routes have been attempted in the past two decades.,,,, Likewise, both gas dependent and gasless techniques have been attempted. However, there is no gold standard alternative EP to conventional open parathyroidectomy through the neck. In this context, we evaluated our novel technique of transoral EP through vestibular route for its feasibility, efficacy and safety.
| ¤ Materials and Methods|| |
This is a prospective pilot study conducted at a tertiary care endocrine surgery department in South India over a period of 15 months from May 2016 to August 2017. We utilised a novel transoral lower vestibular technique for single gland parathyroidectomy instead of open or endoscopic neck parathyroidectomy. Written informed consent was obtained from all the patients for performing this surgery and also to utilise their data for this study. All the clinical, investigative, operative, pathological and follow-up data were catalogued from our prospectively filled database. Relevant computed tomography (CT) and scintigraphic images of parathyroid localisation are shown in [Figure 1]. Statistical analysis was done with SPSS 20.0 (California, Inc.,) version. Descriptive analysis was performed. The study complied with the international ethical norms of the Helsinki Declaration – Ethical Principles for Medical Research Involving Human Subjects, 2004. We termed this novel technique as transoral EP through vestibular access (TOEPVA). The indication for TOEPVA in our protocol was sporadic PHPT with solitary parathyroid adenoma localised on concordant imaging. Contraindications were other causes of hyperparathyroidism, previous thyroid surgery, neck irradiation and non-consenting patients.
|Figure 1: (a) Three port access through lower gingival; (b) intraoperative trocar placement for access|
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Surgical technique of trans-oral endoscopic parathyroidectomy through vestibular access
The position of the patient on the operation table is supine with 30° reverse Trendelenburg position and extension of neck with arms placed by the side of chest. General inhalational anaesthesia was utilised with single lumen reinforced portex endotracheal tube is used for nasotracheal intubation. After draping, neck and oral cavity (lips, lower vestibule and chin) are prepared. A 10 mm frenulotomy incision was placed and dissected through orbicularis oris muscle up to chin with diathermy. Two 5 mm lateral incisions were placed in lower vestibule over lower lip 2 cm away on either side of frenulotomy site. 100 ml of 1:1000 adrenaline/normal saline solution was prepared beforehand, and this was used for hydrodissection through all the three port sites. Veress needle connected with filled in syringe was used to hydrodissect the chin, submental region and neck in subplatysmal plane. This hydrodissection was performed vertically between chin and jugular notch; horizontally between medial borders of both sternomastoid muscles. A long haemostat was used to bluntly dissect through hydrodissected areas for creating working space. Furthermore, a long blunt tipped instrument is used for adequate operative space. 11 mm trocar through frenulotomy for 30° camera and two 5 mm trocars for working ports through lateral port sites were inserted. With a dissector and hook diathermy adequate working space is created under camera vision on high definition monitor. Further operative steps are similar to conventional open parathyroidectomy. The linea alba of strap muscles was opened up, and plane was developed between sternothyroid and sternohyoid muscles on the ipsilateral side of offending parathyroid gland adenoma. A 3-0 vicryl stich was applied through sternohyoid muscle and skin as a retracting stitch by the assistant surgeon. Sternothyroid muscle is cut across with Harmonic Ace shears to reach the thyroid gland. The thyroid gland was retracted medially to identify the enlarged parathyroid gland. With gentle manipulation, parathyroid adenoma was devascularised and separated from surrounding trachea, recurrent laryngeal nerve and thyroid gland. Once it is excised, a custom made endobag was inserted and the specimen was placed in it to be extracted. This manoeuvre helped in preventing any inadvertent breach of capsule and spillage of adenomatous tissue/cells. The endobag with specimen was removed under vision through one of the ports. Superior/inferior counterpart of parathyroid gland on ipsilateral side was inspected. Haemostasis was secured, and no drain was placed. After removing the trocars, interrupted stitches with 3-0 monocryl were applied to the oral mucosa of port sites. The schematic diagram and operative pictures of the procedure are shown in [Figure 2], [Figure 3], [Figure 4].
|Figure 2: Intraoperative view parathyroid adenoma being dissected in thyroid bed|
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|Figure 3: Ex vivo images of excised parathyroid adenoma – (a) superior parathyroid adenoma; (b) left inferior parathyroid adenoma|
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|Figure 4: Post-operative wound images – (a) after mucosal closure; (b) healed wound; (c) external scarless neck|
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Specific pre-operative and post-operative care
The pre-operative preparation starts with biochemical, imaging workup and management plan. Cross-sectional imaging with contrast-enhanced computerised tomography (CECT) scan in the axial, coronal and sagittal sections from the base of the skull to the D4 level was vital in operative planning. Concordance with MIBI scintigraphy is established. Pre-operative chest physiotherapy and incentive spirometry, apart from optimisation of comorbidities (glycaemic, normotensive, haematological, coagulative and cardiac profiles), constitute the cornerstone of surgical success. The patient was insisted on maintaining a good oral hygiene (prophylactic oral antibiotics, brushing twice, gargling with antiseptic mouthwash and avoiding sweets) for 2 days before surgery. Informed consent from the patients; thorough pre-anaesthetic assessment; surgeon anaesthetic discussion; nasotracheal intubation and oral cavity preparation are the commandments for an optimal outcome of TOEPVA.
| ¤ Results|| |
During the study of 15 months, 12 cases of PHPT were treated/operated with TOEPVA by the first author in endocrine surgery department. 7/12 (58%) cases had left inferior parathyroid gland adenoma and 5/12 (42%) had adenoma on the right side (one inferior and superior each). The mean age of the cohort was 21 ± 4.8 years (14–43). Average duration of the disease was 14.2 ± 8.1 months (range: 8–40 months). Operative time of TOEPVA was 112 ± 15 min (95–160). The mean pre-operative serum parathyroid hormone (PTH) levels were 156 ± 32 pg/mL (121–336) and mean intraoperative PTH levels 10 min post-adenoma excision was 26 ± 8.2 pg/mL (5–35), a fall to nearly 1/10th of pre-operative level. All the patients were encouraged for early ambulation and they returned to normal activity and diet within 2 days. Only oral liquids were allowed for first 2 days. All of them were discharged on the 3rd post-operative day. There were no episodes of symptomatic hypocalcemia, neck haematoma, oral cavity bleeding, recurrent laryngeal nerve palsy or surgical site infections. All the patients were followed up for a minimum 1 month. Histopathologies in all the cases were classical benign adenomas.
| ¤ Discussion|| |
A study of the historical journey of thyroidectomy and parathyroidectomy reveals how it was evolved by passionate endocrine and neck surgeons through various phases to the present era of minimal access surgery. Although open conventional neck approach is still the most common approach worldwide, a plethora of EP and ET techniques ranging from totally endoscopic, video-assisted, transaxillary and chest-wall approaches have been already attempted.,,,,,, Even novel approaches such as thoracoscopic, robotic, post-auricular and lateral neck routes have been explored.,,,, Although none of them are validated universally, focussed mini parathyroidectomy and minimally invasive neck parathyroidectomy approaches are favoured alternatives by the majority.,, The objectives of any EP technique are best cosmesis with cure and low morbidity.
Sporadic PHPT occurring in 1:1000 population, constitutes 80%–90% of causes of hyperparathyroidism and majority of PHPT are caused by a autonomously hyperfunctioning benign adenoma developing in a single parathyroid gland in neck or mediastinum. In a classical clinical setting of bone/renal/pancreatic symptoms, diagnosis is established by demonstrating inappropriately elevated serum PTH levels for hypercalcemia. In addition, familial and secondary causes (renal and Vitamin D deficiency) are excluded based on clinical and appropriate biochemical evaluation. Once the diagnosis is confirmed, imaging (scintigraphic and anatomical) is performed for localisation of diseased gland. Surgical excision of all hyperfunctioning parathyroid tissue is the only curative option for PHPT.
Topographically, a concordant imaging of hyperfunctioning parathyroid adenoma on Tc99m MIBI scintigraphy (seen as a hot spot single photon emission CT image) and ultrasonography/CT scan (seen as hypoechoic, vascular lesion in juxta and extrathyroidal location) is essential before planning any focused or EP approaches for optimal outcome.
Traditional approach through horizontal skin crease neck incision for parathyroid exploration was done for the most part of the 20th century. First EP was reported by Gagner in 1996. Later, Husher reported first ET in 1997. Later, Miccoli developed and reported the technique of minimally invasive video-assisted parathyroidectomy (MIVAP) in 1999, which is performed through a 1.5–2 cm transverse incision in lower anterior neck. Since then, growing experience, gain of confidence amongst endocrine surgeons and sophistication of endoscopic equipment have contributed in accelerating the emergence of endoscopic thyroid and parathyroid surgery. However, this progress was more marked in ET compared to EP. Probably, commonality of thyroid disease (thus more opportunity to experiment) and more experience in open thyroid surgery compared to less common PHPT are prime factors for sluggish evolution of EP. Another logical reason for this trend is parathyroidectomy for solitary adenoma usually requires a small 2–3 cm incision (especially for focussed parathyroidectomy) compared to open thyroidectomy which requires 6–10 cm incision. EP through chest wall, mammary and trans-axillary routes use extra-cervical short incisions for superior cosmetic outcome. In trans-axillary approach, both cervical or chest wall scars are avoided. The subsequent scar is hidden in the axilla and remains under sleeves. This is especially suited in modern times, due to increased use of low neck tops exposing the upper anterior chest wall and neck, which is the surgical access area for EP through chest wall/neck. Efficacy wise, conventional cervicotomy, lateral and MIVAP techniques were comparable as shown in several studies.
However, in conventional open or any other cervicotomy approach (focussed or MIVAP), the gland/glands are reached through 2–8 cm lower anterior neck incision, which can result in a scar with hyperesthesia, paraesthesia, more need for analgesia and obvious patient self-awareness. The real need for an extracervical EP emerges, when cosmesis is the major concern for young and unmarried men/women. Furthermore, it avoids the wound/scar-related morbidities such as hypertrophic scar/keloid formation (in dark skinned) and ugly scar, especially in fair-skinned individuals. TOEPVA circumvents all the above cosmetic concerns, as the healing of oral mucosa is brisk and complete, without visible anywhere on the body. We found very scant studies on transoral approach for parathyroidectomy, in spite of its obvious advantages. Karakas et al., in their series of animal/cadaver/human trial studies reported the feasibility and curative efficacy of transoral parathyroidectomy, which they termed as transoral partial parathyroidectomy (TOPP). Later, in human studies, Karakas et al., reported 3/5 (60%) success as TOPP was converted to conventional open technique in two cases. Median operative time reported in that study was 122 min with haematoma of the floor of the mouth in three cases. One patient had transient recurrent laryngeal nerve palsy and another had transient hypoglossal nerve palsy. They concluded, TOPP as a non-sense due to high complication rate. On the contrary, in our study, we found no such morbidities/conversions and opine that TOEPVA is a promising extracervical EP technique of choice especially for unigland sporadic PHPT with comparable mean operative time of 108 min. Recently, similar approach of TOEPVA was reported from Thailand, in which 12 cases have been operated. We opine that any newer procedure becomes easier with growing experience and the learning curve becomes flatter with time as the surgical team overwhelms the technical and ergonomical constraints. The only apparent and documented complication of gas-dependent EP was related to hypercarbia – subcutaneous emphysema, mediastinal emphysema and cardiac arrhythmias., However, it was found that the gas related morbidity is due to high insufflation pressures which can be circumvented by standard low insufflation pressures of 5–6 mm Hg.
Logically, sporadic PHPT with single adenoma is more suited than thyroid nodules for TOEPVA as there is minimal violation of tissues while excising usually small (1–3 cm), benign parathyroid adenomas vis-à -vis ET. Although curative confirmation was obtained with fall in intraoperative PTH levels and histopathology, we cannot comment on long-term recurrence rates in this study. To the best of our knowledge, this is the largest series of transoral parathyroidectomy reported from India and equally largest series in World literature. Although only unigland PHPT was operated in this series, we opine that there is no reason why this TOEPVA is not applicable for multigland sporadic PHPT, as we could inspect normal parathyroids on same side with ease. However, this TOEPVA has limited scope for familial and secondary HPT as exploration of all possible eutopic and ectopic areas of parathyroid glands in neck and mediastinum is not feasible.
| ¤ Conclusions|| |
This novel transoral TOEPVA technique appears to be an optimal alternative for parathyroidectomy especially for unigland sporadic PHPT. However, proper case selection, expertise in minimal access surgery and extensive experience in parathyroid surgery are key to the success of this surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]