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May 2013

 
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Minimally invasive parathyroid surgery was pioneered in the early 1990's primarily by the work of 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 and explore until you find the four parathyroid glands; decide which one is bad and take it out--and keep exploring to see if there are any more bad glands.  As he performed more and more parathyroid surgery, he could not believe that in the era of mini-surgery for galbladders and knee scopes, people had to have their neck slit open to find a tumor the size of an olive. "There had to be a better way! Digging around in somebody's neck hoping to run into a tumor was the dumbest thing I had ever seen in my life!"

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 should see this movie... the entire operation takes less than 13 minutes to test all four parathyroid glands.

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, 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.

Think 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 12%, 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 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. 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 take out. 

Another 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 asleep).

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 19 minutes, and approximately 96% 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. 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 page. 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 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 two. 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%.

Watch 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 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).

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).

ALL 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 third--operation.

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 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 per week. 

About 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!

This page was last updated 05/13/2013