What is the definition of minimally invasive parathyroidectomy (MIP)?
It is the focused exploration/removal of a single abnormal parathyroid gland, which is directed by pre-operative localizing studies (either ultrasound or sestamibi scanning), performed through an incision measuring 2.5 cm (1 in) or less.

Who is eligible for MIP?
Almost everyone, i.e. 85-90% of patients with primary hyperparathyroidism.

Am I still eligible for MIP even though my parathyroid sestamibi scan is negative?
Often yes, for several reasons.

1) I perform my own ultrasound examination for localization of a parathyroid adenoma during the clinic visit. There is good evidence to suggest that ultrasound performed by an experienced surgeon is a better localization test than the sestamibi scan.

2) Parathyroid sestamibi scans are known to be more accurate at specialty centers (80-90% sensitive) than at non-specialty centers (30-70% sensitive). In our experience, among patients with negative scans performed elsewhere, more than half end up having a positive scan when the study is repeated here.

Why isn’t everyone eligible for MIP?
In a small fraction (about 10%) of patients, all imaging studies are negative. Many of these patients will turn out to have multiple gland parathyroid disease. MIP is not appropriate for those cases.

What type of anesthesia is used for MIP and why?
Usually, I perform the procedure under general anesthesia. Occasionally, the procedure may be performed under local anesthesia with sedation for localized adenomas.

Is the gamma probe used during surgery? Is the operation done with radio-guidance (MIRP)?
No. A little over a decade ago, reports emerged proclaiming the benefits of radio-guided parathyroid surgery. This was followed by a similar number of reports stating that radio-guidance was unnecessary. Most experts now agree that the gamma probe does not offer any significant advantages, and it has largely been abandoned by the majority of the surgeons across the country. In my experience, there is no advantage to using the gamma probe for minimally invasive parathyroidectomy.

What surgical approach is used and why?
Most often, I use the focused lateral mini-incision technique, which involves an incision length of 1.5-2.0 cm (about ¾ in). The operation is done under direct vision without the aid of a video-endoscope. This technique generally provides the most direct access to the parathyroid glands. See below.

If there is a non-localizing sestamibi scan and ultrasound examination, I may place a 3cm incision in the midline. This generally gives you adequate access to both sides of the neck, if bilateral exploration for double parathyroid adenomas needs to be performed.

At times, if the parathyroid gland is deep in the neck or behind the esophagus, I may use the videoendoscope as a tool to allow for visualization and dissection in these hard to reach areas. Here’s an example of the visualization that you can obtain with the use of a videoendoscope.

It is important for your surgeon to understand and be able to use these different approaches when necessary.

One size does not fit all when it comes to parathyroid surgery.