Mini-Parathyroid Surgery for Parathyroid Disease.
Nearly all parathyroid tumors can be cured with mini-parathyroid surgery. Parathyroid disease is usually cured in under 20 minutes!

Minimally invasive parathyroid surgery was pioneered in the early 1990's by several parathyroid surgeons, including Dr James Norman, MD while being the Director of Endocrine Surgery at the University of South Florida in Tampa, FL.  Dr Norman learned how to perform parathyroid surgery like all other surgeons: Make a big incision and dissect until you find the four parathyroid glands; decide which one is bad and take it out.  As he performed more and more parathyroid surgery, he could not believe that everybody had to be exposed to a big operation when clearly a small operation could be done on most people with parathyroid disease. There had to be a better way!

This 'Standard Old-Fashioned Parathyroid Surgery' has some very BIG problems! 

The concepts of mini-parathyroid surgery are simple:

Watch a movie of a mini-parathyroid operation. This movie is a "must see". There is no blood and it is very informative! If you have a parathyroid problem, then you MUST see this movie! CLICK HERE.

Mini-Parathyroid 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, only a very RARE few still require the old surgery--based upon their specific circumstances and their anatomy. Thus, virtually ALL patients with parathyroid disease can have a mini parathyroid surgery. Don't let your doctor tell you that you need a big "standard" operation because you have a negative scan... Essentially ALL patients with a negative scan can still have mini surgery!

The big development (invention) which allowed mini parathyroid surgery was the ability to detect which patients had only one bad parathyroid gland BEFORE the operation, and then devise a means to detect that bad gland in the operating room.  Dr Norman developed the technique that is now called minimally invasive parathyroidectomy using intraoperative nuclear mapping (also called minimally invasive radioguided parathyroidectomy (MIRP)) in 1993. This picture shows a single bad parathyroid gland in the lower part of a patient's neck. Now that we know which parathyroid gland is bad, we can operate only in that part of the neck and remove this one bad gland.

Updated, September 2006: During the past several years, the MIRP procedure has clearly become the preferred method of removing parathyroid tumors at many universities in the US and throughout the world. More than 250 scientific articles have been published by more than a dozen US and foreign universities during this time showing that the MIRP has a significantly higher success rate and lower complication rate than standard parathyroid surgery.  This minimal parathyroid surgical technique has gained wide acceptance as the most advanced, least invasive, and preferred method for operating on parathyroids. The old way of making a big incision for all patients with parathyroid disease is GONE! Think twice before you let your surgeon do an old-fashioned operation on your neck!! Make sure he/she is a parathyroid expert and can do mini parathyroid surgery. If he/she is not performing parathyroid surgery once per week, then go somewhere else.

The concept of minimally invasive parathyroid surgery is simple: about 95% of patients with parathyroid disease have just one bad parathyroid...so give them a very small operation to remove just that one bad gland and leave the other 3 alone. In other words, change the big standard operation into something very small, fast, simple, and much less complicated for the vast majority of patients. The best news is that the cure rates reported to date for Mini-Parathyroid Surgery are higher than they would be if the more extensive and complicated operation was performed. 

Parathyroid.com has a complete page of photos illustrating
how MIRP parathyroid surgery is performed.  Click Here

There are numerous potential advantages to
minimally invasive radioguided parathyroidectomy.

First of all, the surgeon has a very good idea which one of the four parathyroid glands is hyperactive prior to beginning the operation. This allows the surgeon to operate on one very small area of the neck rather than exposing the entire neck and both sides of the thyroid. If the operation only takes place on one side of the neck, then the risks of damaging nerves and other important structures on the other side of the neck are eliminated and, therefore, the 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.  

Updated February, 2005:  To see what endocrinologists think about MIRP (an important scientific survey), click here.

Another advantage of the MIRP 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 local anesthesia (i.e., Novocaine) with some IV sedation, 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 for all four parathyroids to find the one which is overactive. In those cases where all four glands need to be identified, the mini incision is about 1.25 inches.  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.

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!) when it involves exploration of both sides of the neck. Some centers (such as the Norman Parathyroid Clinic) are now reporting that as many as 50% of ALL operations take 15 minutes or less, 85% of ALL parathyroid operations can be performed in under 17 minutes, and approximately 95% are performed in under 25 minutes. The ability to do the procedure this quickly means that minimal anesthesia is needed, and unnecessary dissection within the neck is avoided. Combined, 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 just published a recent study (2006) which shows how well people do after a very small, quick operation... this study describes the results of sending 3000 consecutive patients home within 2 hours after the operation was completed).  Even patients over 80 years old have had this mini "band-aid" procedure and are sent home within an hour or two (published results by Drs Politz and Norman, 2006). 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, but most expect a long term cure rate of about 98.5 to 99 percent (remember, the standard operation has a cure rate of about 86 to 94%).  Updated, August 2007:  Dr. Norman is reporting cure rates following minimal parathyroid surgery (MIRP) to be 99.72 percent in ALL patients followed for 2 years or more (thus permanently cured). This is ALL patients, not just those with a positive scan -- yep, this includes people with a negative sestamibi scan. And... we have now sent over 5000 consecutive patients home within 2 hours of the operation--none have spent the night (its a simple operation!).

Note: Dr Norman performed a MIRP mini parathyroid operation LIVE on the Internet on June 14, 2005. The operation was taped and you can watch it here just as it happened. There is no blood, and this movie includes a short lecture by Dr Norman.
Click Here to watch this operation as it happened live!

Who is a Candidate for MIRP Minimally Invasive Parathyroid Surgery?

This new approach to parathyroid surgery has taken the surgical and endocrinology specialties by storm.  The cure rate is significantly higher than the standard parathyroid 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)

Virtually all experts feel that 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) and many experts have embraced it fully. A recent study of endocrinologists has shown that this minimal parathyroid operation is the preferred method to remove parathyroid tumors.  UPDATED, September 2006:  View an abstract of the opinions of nearly 800 endocrinologists surveyed regarding MIRP (click here) Its what 98% of them would have if they had to have parathyroid surgery!

ALL PATIENTS CAN (and should) HAVE MINIMALLY-INVASIVE (RADIOGUIDED) PARATHYROID SURGERY... BUT, depending on the experience of your surgeon, sometimes only those patients in whom a high quality Sestamibi scan shows a single adenoma as the cause for the primary hyperparathyroidism are candidates for the very mini parathyroid operation (the MIRP). THUS, about 89 - 92 % of all patients with primary hyperparathyroidism will localize in this manner and can have this very small out-patient procedure with a typical operating time of 10-20 minutes. The other ~ 8 - 11 % will either not localize on their scan, or will have a scan that is "suggestive".  These patients STILL GET A MINI-OPERATION BY SOME SURGEONS!!!  It is still a mini-operation, and is performed using radioguided techniques but all four glands are examined and all four have their radioactivity probed so the surgeon can determine which one(s) are making too much hormone (are radioactive) and those that are normal (are not radioactive). Remember, a bilateral neck exploration with visualization of all four parathyroid glands has been the gold standard operation for primary hyperparathyroidism since 1925...its just that some expert surgeons can still do these operations in a minimally invasive fashion--usually in less than 20 minutes! The operation is modified in that the surgeon can still use radioguided techniques to help find the bad parathyroid glands and thus speed up the operation, and to decrease the amount of dissection. At the Norman Parathyroid clinic, virtually ALL parathyroid patients go home within 1 to 1.5 hours of the operation... even those who need to have all four glands examined. 

A common question that is asked of us here at Parathyroid.com is this: "If MIRP mini parathyroid surgery is so much better than the standard old-fashioned parathyroid surgery, why isn't every surgeon do it?"

The answer is simple. Parathyroid disease is NOT very common. The average surgeon performs only 1 or 2 of these operations per year. However, there is no incentive for this doctor to take the necessary training on how to perform radioguided surgery. It is not economically wise for them to take time off of work to travel to a training center and pay for a surgery training course if they are only going to do something a few times per year. Similarly, the hospital that only sees a few of these cases per year is not willing to spend several hundred thousand dollars (about $200,000) to purchase equipment that is needed for this operation--it doesn't make economic sense for them. If the hospital doesn't have a good nuclear medicine department that can support this surgeon (and perform state-of-the-art sestamibi scans in less than 15 minutes), then there is no way the doctor can get his patients into the operating room while the patient's tumor is still radioactive. If you have had a sestamibi scan that took several hours to complete, you will understand this concept...the scan has to be completed in less than 20 minutes, and most nuclear medicine departments simply do not have the expertise to make this happen.

Thus, there are a number of reasons that MIRP mini-parathyroid surgery is not widely available...mostly due to economic reasons, and lack of experience. There simply are not enough parathyroid patients in the world to allow for an expert parathyroid surgeon in every town. Its just too rare of a disease! Just ask your family doctor how many patients they have EVER seen with this disease, and you will understand. Would you fly in an airplane where the pilot only flys this type of airplane a couple of times per year? Heck no you wouldn't, and the airlines won't let it happen to you... but your insurance company will!

Another misconception is that the probe is used just to help find the radioactive parathyroid tumor. This is WRONG... The probe is used to determine if the parathyroid that has been removed is the one that is causing the hyperparathyroidism. This is an extremely important concept! The probe can tell the difference between NORMAL parathyroid glands and over-active parathyroid glands. This is the most important part of using the probe! This prevents the surgeon from removing normal parathyroid glands (which is done all the time!!!) and assures that the bad (over-active) parathyroid gland is removed before the operation is concluded (yep, this happens all the time when inexperienced surgeons perform parathyroid surgery).

Another 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 22% 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--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! 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 once per week OR MORE!.

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 nearly 2000 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 this operation AT LEAST once per week. Otherwise, keep looking.

At the Norman Endocrine Surgery Clinic, parathyroid surgery is all we do. We invented the techniques and tools used in mini-parathyroid surgery. Read what our patients say about how they feel after having their parathyroid tumor removed: Click Here 

This page was last updated 08/19/2007