Know with a very high degree of accuracy where the tumor is
located before the operation so you don't have to dissect all of the
neck structures trying to find it. This does NOT mean the patient
needs a positive scan...or any scan for that matter. You do NOT
need a positive scan to have a mini-operation! Be
careful here folks... there are dozens of "wanna-be"
parathyroid experts who put up a fancy website and claim to do
mini-parathyroid surgery--the guys in New York and Atlanta come to
mind. What they won't tell you is they won't operate if your scan is
negative, and they will ONLY remove the tumor that shows on the scan.
They won't look at all four parathyroid glands. This isn't a scam, but
it is not the best surgical care. Be careful of a surgeon that says
take out the tumor that shows on the scan and then measure your
hormone levels to see if we got it all".
That is an operation a surgery intern could do. That is not an
operation performed by an expert. Your surgeon should examine
all four parathyroid glands... If you watch our video
you will understand this concept.
Know with a very high degree of accuracy where the tumor is NOT
located prior to the operation. This is a more difficult concept to
understand, but this is what allows a select few surgeons perform
mini-parathyroid surgery on ALL patients - not just patients who have
a positive scan. This is the concept we live by... knowing where the
tumor is NOT located is the most important thing that a scan can tell
you. Thus, the negative scan is just as good as the positive
scan! It just means that surgeons should understand where the tumor is
NOT located so they don't have to explore everywhere. Read
Dr Norman's invited editorial in the Journal of Surgical Oncology in
2012 discussing that negative scan patients should have mini surgery
also, and that doctors should stop emphasizing the scans. Norman
J. Controversies in parathyroid surgery: The quest for a
"mini" unilateral parathyroid operation seems to have gone
too far. J
Surg Oncol. 2012 Jan;105(1):1-3
Make a small incision and take out the bad parathyroid and examine
the status of the other 3 parathyroid glands. Use technology to determine if and when the patient is cured. Use more
modern science, and not big knives! You must make sure all the other
glands are asleep (making no hormone), because about 25-30% of people will need more than one
parathyroid gland removed.
Do not remove the normal parathyroid glands. This sounds obvious,
but normal parathyroid glands are removed at about 90% of parathyroid
operations because of surgeon inexperience and the lack of the newest
technology in the operating room that can tell the difference between
a gland that is asleep (dormant) and one that is awake and making
hormone. Two or three parathyroid glands will be normal in about 98.5% of
people. Virtually 100% of patients that come to us for their second
(or third) parathyroid operation after a failed operation somewhere
else have had one or more normal parathyroid glands removed because
the surgeon isn't experienced enough to distinguish normal glands from
Don't "EXPLORE" the entire neck like surgeons have done
since 1925. Use modern tools and techniques to help find the bad
gland, and don't go on a 'wild goose chase'. Avoid
"exploring" all parts of the neck! This
is very important... use tools and technology (and experience), and
not brute force!
If you can make a small incision, then you can do the operation as
an outpatient with very light anesthesia (over
99% of our last 27,000 parathyroid patients have gone home
within 3 hours of their operation).
Cure rates should be higher if we can do a more precise operation
-- and they are. Cure rates for MIRP are expected to be around 95% if
your surgeon does two (2) or more of these operations per week
(we average about 65 per week and have a cure rate of 99.6%).
We believe strongly that almost everybody needs all four glands examined,
but this can be done using a MUCH smaller operation using radioguided
(MIRP) techniques. The probe
tells the doctor which glands are bad and which ones are good! ALL
PATIENTS CAN HAVE A MINI PARATHYROID OPERATION BY A PARATHYROID
SPECIALIST WHO DOES MINI PARATHYROID SURGERY REGULARLY. Watch
our video--the best page of this website. If you understand the
operation video page of this website, you will understand more about parathyroid
disease than most endocrinologists...it is sad, but true.
Don't wait until patients suffer from depression, fatigue, kidney
stones and osteoporosis to tell them that there was a 15-20 minute
operation that could have prevented these complications long ago! Fix
the parathyroid problem and remove the parathyroid tumor before it
ruins the patient's life!
Don't wait until the woman gets breast cancer before you tell her
that the high calcium in her blood could have been the cause of the
breast cancer. Get the darn tumor removed!
Bottom line... It is all about the surgeon and his/her operating
team. You must get an experienced surgeon. If your surgeon says he/she has all the
tools to do mini-parathyroid surgery, but they don't perform two (2) of
these operations per week (or more)... then go somewhere else.
Would you fly on a plane that the pilot only flies a
couple of times per month... or less? Parathyroid surgery
is more about the experience of the surgeon than the tools he/she
uses. We know many people can't come to Tampa for an operation, but
please, pick an
a movie of a mini-parathyroid operation. This movie is a "must
There is no blood and it is very informative! If you have a
parathyroid problem, then you should see this movie... the entire
operation takes less than 13 minutes to test all four parathyroid glands.
surgery is now available, and has become the preferred method of operating
on parathyroid glands. Sorry, but this is not available everywhere, but it
should be. Just like laparoscopic gallbladder surgery
has replaced the old-fashioned 'big" gallbladder operation, Mini
Parathyroid Surgery has replaced the old fashioned parathyroid
operation. Just like laparoscopic gallbladder surgery, almost all patients can have the new mini-parathyroid operation,
and in our opinion, nobody requires the old big "exploratory"
surgery. Don't let your doctor tell you that you need a
big "standard" operation because you have a negative scan... All
patients with a negative scan can still have mini surgery--if your surgeon
knows how to do it.
twice before you let your surgeon do an old-fashioned parathyroid operation on your
neck. Also, be leery of a surgeon who says that they see the tumor on the
scan and they will go remove it and measure your PTH hormone while you are
on the operating table. This technique will have a failure of at least
and even if you are one of the 88% that are cured, you have a 10-11%
chance of needing another operation in the next 10 years. This is why we
examine and determine the activity of all four parathyroid glands in
almost all our patients. Please make sure your surgeon is a parathyroid expert and can do mini parathyroid
surgery. If he/she is not performing parathyroid surgery at least once per week,
then go somewhere else. If you have to spend the night in the hospital
after your parathyroid operation, then go somewhere else. If they tell you
that they may have to take out all of your parathyroid glands and put one
in your arm... then RUN as fast as you can! If they say they are going to put you asleep
with a tube that monitors your voice box nerve, then you may want to see
somebody else. If your surgeon can't tell you that this is easy with an
expected complication rate of less than 1% and a cure rate of over 95%,
then go somewhere else.
There are numerous potential
minimally invasive radioguided parathyroidectomy.
all, the surgeon has a very good idea which one of the four parathyroid glands is
hyperactive prior to beginning the operation. Even if a patient has
a negative scan, there is so much information on the scan (where the tumor
is NOT located) that the experienced surgeon knows where to go find the
tumor. This allows the surgeon to operate on one
very small area of the neck (right around the thyroid gland) rather than exposing the entire neck. If the operation only takes place in a much smaller area of
the neck then the potential risks of this procedure are expected to be less than half
of that seen during a complete neck exploration (a number of reports
of MIRPs in the medical literature have shown a lower complication
rate about 80% less than the standard operation). If you are contemplating
parathyroid surgery, ask your doctors about this procedure, you will be glad you did.
You wouldn't have the old fashioned gallbladder surgery, so don't settle
for a parathyroid operation designed in 1925! If your doctor is not aware
of this operation, please feel free to have them contact
Dr Norman directly. The picture here shows a very band-aid size
for a woman weighing about 135 pounds. This lady is 4 days after her
operation. The band-aid comes off in one week. There are no stitches to
advantage of the MIRP parathyroid surgery technique is that it almost NEVER requires
general anesthesia where a tube is put down your throat and a machine
breathes for you during the operation. Mini-parathyroid surgery is
usually performed using IV sedation (like getting a colonoscopy), or using a very light general anesthesia (called LMA). LMA
anesthesia allows the patient to be out for the procedure, but awake
enough that they breathe for themselves and wake up completely within a
minute or two. The operation is
typically performed through a 2.5 cm (1 inch) incision (shown in yellow) rather than
the usual 12 cm (6 to 8 inch) incision (shown in red). The surgeon is able to
complete the operation through this smaller incision because he/she does not have to
search the entire neck... the "negative" information on
EVERY good quality scan tells the surgeon where they do NOT have to
operate. Note that the
size of the incision is based upon surgeon experience, and NOT on the
patient's disease--this cannot be overemphasized).
The probe that is used directs the surgeon right to the bad gland... it also allows the
parathyroid adenoma to be removed in
much less time. The two keys to this operation are the experience of
the surgeon, and the radioactive probe used to identify the parathyroid
glands and prove that the parathyroid removed is the one that is making
all the excess hormone (and the other three are normal glands that are
Nerve Monitoring: Some surgeons will tell
you that they will put a tube down your throat so they can monitor your
vocal cord nerves. This is something we would never do. This is a crutch
for surgeons who don't operate around the vocal cord nerve very often.
They are doing it for one reason... and that reason is not YOU. They are
doing it so you can't sue them if they cut your vocal cord nerve. Go
ahead, ask them this question and they will tell you that the tube does
not protect your nerve or decrease the risk of nerve injury--the tube is
put in to protect the SURGEON from malpractice lawsuits. We think the tube
is silly and reflects poorly on the surgeon. However, some good
surgeons use this tube--just don't fall for the hype--the tube is not to
protect you, the tube is to protect the surgeon's wallet.
The average operative time to remove the diseased
parathyroid gland using this technique is about 25 minutes as compared to an operation
which can take up to four hours (or more!). At our center, about 65% of all operations take
16 minutes or less, 85% of all parathyroid operations can be performed in under
20 minutes, and
are performed in under 30 minutes. The ability to do
the procedure this quickly means that minimal anesthesia is needed,
and unnecessary dissection within the neck is avoided. These numbers
are current numbers where we look at all four parathyroid glands.
Remember, the only way to get over 99% cure rate and to make sure you
don't need a second operation is to assess all four parathyroid glands in
all patients, but this is a very specialized technique that few surgeons
can do. This is discussed in detail on the next
these advantages allow almost all patients to be sent home within an hour or two of the
operation rather than spending one or two days in the hospital. It
also means that the complication rate is less than half, and in some
institutions, near zero. Most surgeons who are performing this type of
mini parathyroid surgery send virtually all patients home following this
procedure. Drs. Norman and Politz have published several scientific
studies demonstrating how well people do after a very small, quick
operation. In 2010 they published a paper on 10,000 consecutive patients who were sent home within 3
hours of their parathyroid operation--this is now very safe. Now, in
2012, we have sent home over 17,500 patients within 2 hours of their
operation. We've had over 250 patients over 80 years old who had this
mini "band-aid" procedure and are sent home within an hour or
The small wound heals quickly and only very rarely do
patients need any prescription pain medications. Reported cure rates for this minimal
approach are 99% by some experts, (remember, the standard operation has a cure
rate of about 86 to 92%). At our center, we expect cure rates to be
about 99.4 to 99.8%.
* Over 75 publications in medical journals have shown that the cost of performing a MIRP is significantly less
than the standard operation; as much as 1/3 the overall cost.
the newest video filmed 8/2/11. This is un-scripted and shows a
complete parathyroid operation that is the most advanced operation
available. All four parathyroid glands are evaluated, two tumors are
removed and the entire operation takes 13 minutes. This is the best page
on this website.
Who is a Candidate for MIRP Minimally Invasive Parathyroid
This new approach
to parathyroid surgery has taken the surgical and endocrinology specialties by
storm. The cure rate is significantly higher than the standard
operation and the complication rate is near zero (far less than one
percent if done by an experienced endocrine surgeon). This is changing the way all
doctors look at parathyroid disease. Since hyperparathyroidism can now be fixed easily for
almost all patients, many experts are sending all of their
parathyroid patients for this
minimal operation. They feel it is much riskier to wait around and develop
osteoporosis or kidney stones than it is to have mini parathyroid
surgery. Besides, the
operation makes the majority of people with parathyroid disease feel better and enjoy life more!
(see the page on symptoms).
The advent of mini-parathyroid surgery has
revolutionized the way parathyroid disease is managed.
More and more surgeons are being trained in radioguided
surgery for breast cancer and malignant melanoma,
as well as parathyroids and so radioguided surgery is becoming much more common.
The results of this minimal approach to remove diseased parathyroid
glands has now been proven to be better than
the gold standard parathyroid operation (the BIG operation).
PATIENTS CAN (and should) HAVE MINIMALLY-INVASIVE (RADIOGUIDED) PARATHYROID SURGERY... BUT,
this depends on the experience of your surgeon. Be smart and make sure
your surgeon does parathyroid surgery at least a few times every week...
or the chances of a poor outcome will much higher. Ask your other doctors,
they will all tell you... you must find the most experienced surgeon for
parathyroid surgery. About 20% of our practice is operating on patients who have had
a previous operation by an experienced surgeon who now needs a second--or
common question is whether a thyroid nodule can be looked at during a MIRP
mini-parathyroid operation. Of course the answer is yes. The
parathyroid glands live behind the thyroid, thus the thyroid must be
examined during every parathyroid operation. If anybody suggests that they
can do a parathyroid operation of any sort and not completely inspect the
thyroid gland for thyroid problems, then they are confused. About 28% of
all parathyroid patients operated on at the Norman Parathyroid clinic have
some problem detected in their thyroid that requires a biopsy or removal
of a thyroid nodule. This adds 30 seconds to 10 minutes to a parathyroid
operation (usually about 2-5 minutes)--but everything else is the same. These patients still go home
in an hour or two. Still the same 1 inch incision. Still the same
mini-operation! This is discussed in both of our operation videos. In
the 2005 video, we actually remove a small thyroid nodule.
Look folks, obviously, we can't operate on every parathyroid patient
in the U.S. -- nor do we want to -- but please choose your surgeon wisely and
pick one that uses the most up to date equipment and knows how to use it.
Pick a surgeon that is able to take care of your thyroid problem if one is
found at the time of the parathyroid surgery, and pick a surgeon that does
parathyroid surgery FREQUENTLY!... and that means about twice per week or
more... parathyroid surgery twice per week or more, not thyroid surgery.
How many men play golf? How many of them are professional
golfers? How many professional golfers win a major tournament each year?
Do you get our point? Please, pick your surgeon wisely, we hate seeing
people get a bad operation, and we see it several times every day. If this
operation was easy and everybody could do it, do you think over 2300
people per year would travel to Tampa to get it done? We can't
operate on everybody with parathyroid disease... but please... do your
homework and find a surgeon that does PARATHYROID operation at least twice
20% of our practice is operating on people who were
not cured by their first surgeon, and almost 10% of them can't talk--and
almost all of them had a nerve monitoring endotracheal tube during their
first operation. Be
smart! Every day we operate on two or three people who had a local
surgeon perform their parathyroid operation... telling the patient
"we do the same operation as the guys in Tampa". Yep, and I play
golf with the same golf clubs as Tiger Woods. We can't operate on
everybody (we know this!), but please don't let the local dude operate on
you because he did your mom's breast operation and he fixed uncle Harry's
hernia, and he did a good job with that!