Mini-parathyroid
surgery has become the preferred way to treat parathyroid disease. This is
the second page on mini-parathyroid surgery--discussing how MIRP mini
parathyroid surgery is performed. MIRP mini surgery is also called
"radioguided parathyroid surgery", as discussed below. There
are four keys to mini parathyroid surgery: 1) The surgeon should
have a good idea which parathyroid gland is bad before operating (a
positive scan is NOT required), 2)
the surgeon should know with near 100% accuracy where the parathyroid
tumor(s) is NOT located, 3) the surgeon uses a special probe in the operating room that can
tell the difference between a parathyroid gland that is making lots of
parathyroid hormone (PTH) and which glands are asleep (not making any
PTH), and 4), the surgeon can measure how much hormone each
of the parathyroid glands are making during the operation. Importantly, the standard
parathyroid operation does not do either of these last two important steps,
rather the old way simply requires the surgeon to dissect all parts of the
neck and "explore" for the parathyroids, hoping to find one that
is big so it can be removed. The probe can tell the difference between a
normal parathyroid gland and a diseased gland, so normal glands are not
removed... and the surgeon knows when the patient is cured by removing a
parathyroid tumor that is making LOTS of hormone. The probe tells the
surgeon when the bad gland has been removed, and it prevents the removal
of normal glands. Look folks, the days of "exploring" people's
necks for parathyroid glands are gone. If your surgeon uses the word
"explore", then get up and walk out.
Also, if your surgeon wants to operate and take out the gland that
shows up on the scan and then quit the operation without checking the
other glands then you may want to think about finding a more experienced
surgeon (watch our operation video
so you understand why it is best check all the other glands). If your
surgeon is going to remove the one parathyroid that shows on the scan and
then "measure the hormone in your blood to see if it goes down by
50%", then understand that you have a 25% chance of needing a second
operation some time down the road. That is what less experienced surgeons
do since it is the simple thing. Heck, your gynecologist can operate to
remove the parathyroid tumor that shows on your scan--it doesn't take an
expert to do that! HOWEVER, if that is all they are going to do, discuss
with them what the plan will be if you are not cured. Who will perform the
second parathyroid operation, and how much more dangerous will it be the
second time. The "fall in 50%" rule is a silly rule that doesn't
work very well. Just ask them and see what kind of reaction you get.
As developed by Dr
James Norman (at the University of South Florida in Tampa) in the
early 1990's, the radioguided mini approach to the parathyroid gland
has now been shown to 1) have the highest cure rate of all
parathyroid operations, 2) have the lowest complication rate of all
parathyroid operations, 3) require the smallest incision and least
amount of dissection, 4) is able to be performed under "Light Anesthesia"
where almost all patients are not intubated, 5) cost significantly less than other parathyroid operations,
6) require the least amount of time in the hospital of all
parathyroid surgeries (about 1.5 hours post-op typically), and 6) has a lower
complication rate compared to a standard parathyroid operation.
NOTE: All patients are candidates for a mini-parathyroid
surgery. In
other words, all patients should discuss mini-parathyroid surgery with
their surgeon to see if this option is possible. Also note that a few
expert surgeons can perform mini parathyroid surgery on ALL patients,
regardless of scan results, and regardless of the presence of co-existing
thyroid disease (we perform mini surgery on all patients regardless of
scan results). If
your doctor cannot give you a 95% guarantee that your operation will be a
mini-operation, then you may want to go somewhere else. If your doctor
says you can't have a mini-operation because your scan is negative, you
really should go somewhere else. Mini surgery can be done on 100% of
patients if your surgeon knows how to do it. Mini surgery does NOT require
a positive parathyroid scan.
IMPORTANT... Ask your surgeon if he/she is going to evaluate all four
parathyroid glands. This is what you want. If your surgeon is going to
remove one gland--the bad gland they see on the scan--and then stop the
operation, you have a 10% chance of needing another operation in the next 1
year, and an additional 16% chance of needing a second operation in the next 10 years.
Be careful of surgeons who say they can do a mini parathyroid
operation because you have a positive scan, and their plan is to take out
the one bad gland they see on a scan and quit the operation. About 20% of
ALL the operations we perform every week are on people who had this mini, one-side
parathyroid surgery. Although Dr Norman is one of the
"inventors" of one-side parathyroid surgery in the mid 1990's,
he does NOT do this one-side operation any more. The failure rate is too
high. Watch the video of a 13 minute
MIRP parathyroid operation where all four parathyroid glands are examined
and TWO tumors are removed--even though the scan only showed only ONE tumor.
Between 25 and 30% of people have more than one tumor.
How Minimally Invasive Parathyroid (MIRP)
Surgery Works
Step
1. Make the over active parathyroid gland radioactive so it can be
differentiated from all the other structures in the neck. The key to the success of
this technique was the development of the Sestamibi scan in the early 1990's which makes
only parathyroid tumors radioactive for about 3-4 hours...normal parathyroid glands will
NOT become radioactive (normal glands are asleep, and thus they don't
absorb the radioactive dye). This simple technique requires the patient to be given
a very small dose of the same drug that is used to examine the heart
during heart stress tests. Using special techniques, the bad parathyroid
gland will show itself to the surgeon. The surgeon should still look at
all four glands if you expect a cure rate over 90%. If your surgeon does
not have the expertise to look at all four glands, then he/she will look
at only the gland that shows up on the scan. This is fine, however, you
must understand that the failure rate will be higher. Ten or fifteen
percent of these patients will require another operation because they are
not cured.
Step
2.
Operate to see all four parathyroid glands, but operate only where necessary.
The most important information seen on the sestamibi scan is
not where the tumor is located, but where the tumor is NOT located.
Knowing where the tumors are not located allows an experienced surgeon to
see all four parathyroid glands (located where they are supposed to be
located) to make sure a second, (or rarely a third) tumor is not present. Now that the surgeon knows
that the operation will not require extensive "exploration" of the
neck, he/she can make a much smaller incision. The picture on the left shows the 3/4 inch incision in the lower neck
which is typically made for the minimal parathyroid operation (MIRP). The patient's head
is to the top of the picture and a blue pen was used to mark the outline of her collar
bones and the top of her breast bone (the sternum). Now it's easy to see how this small
operation can be performed using only local (or twilight) anesthesia rather than putting the patient
asleep under general anesthesia. Note: even when undergoing the operation under local
anesthesia, the anesthesiologist will give the patient a bit of sedative medications
through their veins so the patient really won't be aware what is going on and
they NEVER remember the procedure. Read more about anesthesia for MIRPs
below. REMEMBER, the old-fashioned standard operation requires a neck incision
6 to 8 (or even 10) inches
in length (click here to see a
picture of the old parathyroid incision).
Step 3.
Use a miniature hand-held radiation detecting probe to measure the
amount of activity of each parathyroid gland. The really neat thing about this procedure is that the
parathyroid tumor is radioactive for about 3-4 hours...so the surgeon can
use this to determine good parathyroid glands (they are asleep and making
no hormone) from bad parathyroid glands (they are making too much
hormone). The probe measures the amount of radioactivity in each
parathyroid gland which is proportional to the amount of hormone being
produced. The probe shown here is made by US Surgical Corporation (Norwalk, CT) and
was designed and patented by Dr Norman. Since the radioactivity only lasts 3-4 hours, the
operation needs to be completed during this period of time. The old way of operating and
dissecting throughout the entire neck of
all patients with parathyroid disease is giving way to this much improved minimal
parathyroid operation for ALL patients. Note... this lets the
surgeon know when a gland is normal so it doesn't get removed, and makes
sure that ALL of the bad glands are removed--so the patient doesn't need a
second operation some months or years later. And, YES, an experienced parathyroid
surgeon can see all four parathyroid glands using an incision that is 1
inch or less (slightly bigger in patients over 250 pounds). Our video
explains this better.
Step 4.
Remove the radioactive parathyroid tumor. The next step is for the surgeon to
dissect the overactive parathyroid tumor away from the rest of the neck structures and
remove it. In this picture we put yellow dots around the parathyroid tumor to make it
easier to see. This overactive parathyroid was about the size of a large black olive which
is fairly typical. Remember, a normal parathyroid gland is supposed to be the size of a pea or
grain of rice.
Parathyroid glands only have a single small artery and vein. This picture shows a very small clip
being put on the artery and vein prior to removing the enlarged parathyroid.
If you haven't seen our page of pictures of parathyroid tumors that were
removed from patient's necks, you need to see that page soon... Click
Here to see pictures.
Step
5. Measure the radioactivity in the parathyroid tumor to help make sure that the
patient is cured of their disease. The most
important aspect of radioguided parathyroid surgery is one that most
surgeons who have not been trained in this technique miss (and it has us
very frustrated!). The probe is not used to help find the tumor, it
is used to determine how much hormone the tumor (or ANY parathyroid gland)
is producing. Since the object of the operation is to remove the
source of excess parathyroid hormone production, the probe can be used to
determine the difference between an adenoma, a hyperplastic parathyroid
gland, and a normal parathyroid gland.... Once the enlarged parathyroid
gland is out, the
probe is placed on it to make sure that the radioactive tumor has been removed. The amount
of radioactivity contained within the gland helps the surgeon be confident that the
operation is complete and whether or not any other parathyroid glands will need to be
dissected out... or even removed. Performed correctly, this method is much more
accurate than measuring PTH levels during the operation (over 99%
accuracy).
Step 6.
Put on the bandage and get ready to go home. Because the MIRP
mini-parathyroid operation can
usually be performed quickly with very limited dissection, patients are quite
ready to
go home within an hour or two. That is fine and they can return to normal duties as soon as they wish
(usually the next day). The bandage should be kept dry for about 24 hours, then the
patient can shower and do anything they want. The bandage should be left in place about a week. No laboratory tests
are required for about 2 months. Of course, this and all
of the other decisions and treatments discussed on this page will be up to your
doctors...the key is to treat every patient like an individual...each has a special case
and special needs. Your case may be different depending on MANY variables, so
discuss all of this in detail with your surgeon and work with him/her so you get what is
best for YOU.
Why The Experts Are No Longer Performing One-Side
Parathyroid Surgery.
Prior to 1993, all parathyroid surgery was performed by
the surgeon looking at all four parathyroid glands, meaning that the
operation was on both sides of the neck. Without some of the modern tools
and hormone measuring devices that we have now, this was a HUGE operation
taking 4-6 hours. By 1994 things switched to a one-side parathyroid
operation for people with positive scans because of work done by Dr Norman
and others who advocated taking out the tumor that showed up on the scan
and measuring hormones to predict if the patient was cured--avoiding
operating on both sides of the neck. So, between 1995 and 2010, most
surgeons would operate on one side of the neck, remove the tumor that was
seen on the scan, and then measure the parathyroid hormone to see if the
amount of hormone in the blood decreased by a substantial amount. If it
did, the operation was concluded. Most surgeons continue to do this now,
and it is what these surgeons advertise on the Internet as "Mini
Parathyroid Surgery".
HOWEVER, when we look back at what happened to all those
patients that we operated on only ONE side of their neck, we see that a
lot of these people had to come back and have a second operation because
they had a second tumor in their neck that was not removed during the
first operation (because the first operation did not look at all four
parathyroid glands). Remember, Dr Norman was the biggest advocate of
unilateral (one-side) parathyroid surgery for the past 15 years, and is
the "father" of mini-parathyroid surgery (Wikipedia).
However, Dr Norman and his partners (Drs Politz and Lopez) stopped doing
one-side parathyroid surgery in 2008 because the failure rate was too
high. People who had a large parathyroid tumor identified on a scan, and
then had this large parathyroid tumor removed by us in the operating
room--we expected to be cured. But slowly they started coming back for a
second operation. This was in contrast to the people who had a negative
scan and we looked at all four of their parathyroid glands during the
operation. The people who had negative scans had operations that took
about 3 minutes longer, but they were virtually all cured forever because
we evaluated all four of their glands, while those with a positive scan
had a 12% chance of needing a second operation in the next 10 years.
Remember, these failure rates happened to us at our skill level--we're by
far the best at this in the world. Even with our experience we can't be
sure we cure people forever unless we examine all four parathyroid glands.
Thus, if you come to our center, unless certain circumstances exist, we
will look at all four of your parathyroid glands, and we will look you in
the eye when it is over and tell you about each of them, and how much
hormone each of your 4 glands is making. Please watch
the video and you will understand this better--we do the same
operation on people with positive scans and negative scans, because the
only way to cure somebody long-term (for many years) is to look at all
four glands in almost all patients. Yes, it is still done with the same
small incision, but now you know why our small incisions are always in the
middle of the neck--so we can see the parathyroid glands on both sides.
This graph shows what happened to 17,500 patients that we
operated on between 1994 and 2010. The vertical axis is the cure rate. The
red line shows the people that had a positive scan and we operated on one
side of the neck only. The blue line shows people that we operated on both
sides of the neck and examined all four parathyroid glands (because the
scan was negative, or for a number of other reasons). 
It turns out, if we operated on you between 1994 and 2010
and we looked at all four of your parathyroid glands, we never saw you
again...you were cured and you stayed cured. You are on the blue
line. If we operated on one side of your neck to remove the tumor
and didn't examine the glands on the other side of the neck to see if
there was a second, smaller tumor, we had a 10% chance of seeing you again
in the next ten years to operate on the other side of your neck. We love
our patients, but this isn't a good reason to see them twice! Now you know
why we look at all four parathyroid glands on about 98% of the operations
we do. Because we are smarter now, and we want to cure you (and make you
feel better!) for ever, not for just a few months or weeks. Remember, the
down side for the patient isn't just that they need a second operation, it
is that they never feel as good as they should. They continue to get
worsening osteoporosis, fatigue, stones, blah, blah, blah...
Now that we've done this operation over 18,000 times, it
takes us only about 17 minutes on average to do a 4-gland operation, and
this includes people with thyroid problems. If there are no thyroid
problems, the operation usually is about 15-16 minutes. Did you watch the video?
One final note: We can't
operate on every patient with this problem. About 8,000 different people
view this website EVERY DAY, and they are not all coming to Tampa for
surgery! Most of you are going to be operated on by surgeons with little
or modest experience with parathyroid surgery. These surgeons are going to
do the one-side operation. It is easier for them, and it is safer for you
if they aren't doing at least one of these operations per week. Heck,
80-85% of the time this will turn out just fine. If a surgeon doesn't do
parathyroid surgery at least once per week, then they are better off only
operating on one side of your neck. And, it makes it easier for an expert
to re-operate if the first surgeon is unsuccessful. HOWEVER, you
must realize that after your operation, your calcium should be in the 9's,
not the 10's. If your calcium level is still above 10.0 mg/dl, then you
still have a parathyroid tumor in your neck and the one-side operation did
not cure you. Be smart folks. Pick your surgeon wisely. Ask good
questions. And do NOT let a negative scan keep you from getting your
tumor removed. Scans do not matter!
The typical MIRP operation at the Norman Parathyroid
Clinic:
Updated: 05/13/2013
May
2013
