We do not use an endotracheal tube on our patients. That means we don't put a tube down into the trachea for deep general anesthesia. This patient is asleep enough so he doesn't feel anything or move, but he is awake enough so that he breathes on his own and not by machine. The drugs used are similar to the drugs used for colonoscopy--they are given into the vein. We don't need big-time, aggressive anesthesia and "nerve monitoring" for such a quick operation. If your surgeon wants to put a tube down your trachea so he/she can "monitor" your vocal cord nerves, you must understand that this means you are having a bigger operation than you need (and your chance of vocal cord injury is more than double). The CalciumPro app has a complete section on "How to Find a Parathyroid Surgeon". Another reason to download the CalciumPro parathyroid diagnosis and risk-assessment app!

We put the incision in the same place on all patients. The incision must be put in the middle so we can get to all the parathyroid glands on BOTH sides of the neck. Any surgeon who puts an incision off to one side or the other should have his/her hands smacked with a ruler--it is never done by an expert. Any operation that has the incision placed off to one side has a cure rate of 85% at best (you will understand that after you see the video).
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With a number of surgical tricks (that you can't appreciate completely because you can't see into the wound), we can see all four parathyroid glands through this incision that is just under 1 inch in this man. We do not need a big incision to see all four glands. Also, we evaluate the entire thyroid through this small incision. Most of our operations are done through incisions less than 1 inch.

We were excited during this operation when we found that this man had TWO parathyroid tumors because it gave us the perfect opportunity to show that sestamibi scans are over-emphasized and are usually wrong. This case was not staged, but several important points about sestamibi scans are made during this video such that you may think we knew that this man had two tumors ahead of time--but we did not!  We look at all four parathyroid glands in almost every parathyroid operation we do--because you can't tell by scan which glands are bad and how many bad ones exist. This is why we roll our eyes when our patients have a scan and then ask us "how many bad parathyroid glands do I have?"  We tell them: "We don't know, we haven't performed the operation yet". Listen up folks... scans can never tell you how many glands are bad. If you learn nothing else from this parathyroid operation video, then learn that scans are not accurate, and are just a tool we use. The scan will not hold the answer to your problems. Scans cause more problems than they solve Scans are wrong more than they are right! Chill on the scan folks!

This sestamibi scan clearly shows a normal thyroid and one large parathyroid tumor. This scan is as good as it gets, and it is absolutely perfectly positive showing ONE parathyroid tumor. Note that the scan is better and brighter in real life, and on the video--it doesn't reproduce well here.  About 18 years ago when Dr Norman was first developing mini-parathyroid surgery he was of the opinion that a very good quality sestamibi scan (like this) showing a single parathyroid tumor would allow for a one-side (unilateral) parathyroid operation. If there was ANY question about a second tumor, then both sides of the neck would be examined, but in cases like this, he would have (many thousands of operations ago) operated on only one side of this man's neck. This case is the absolute perfect example that shows a one-side parathyroid operation will have a cure rate of only 90-93% by even our surgeons (who do 50 a week) because some of these folks will have a second tumor that CANNOT BE DETECTED EVEN THE BEST SCAN IN THE WORLD. Lesser experienced surgeons using scans that are not as good get cure rates of 85-90% with one-side operations. At virtually every other hospital in the world, this man would have had a one-side (unilateral) parathyroid operation the way Dr Norman developed mini-parathyroid surgery 10-15 years ago and this man would have been "better" but not cured. He would have been "better" because a large parathyroid tumor was removed, but he would not have been cured and he would need a second operation anywhere from 3 months to 2 years later to remove the second tumor (that was smaller, and not detected on the scan). We rarely do a one-side parathyroid operation any more, for the reason you see on this video--a second parathyroid tumor can be hiding and the scans will miss it! Besides, as you saw on the video, we can look at all four parathyroid glands so fast it doesn't make much sense not to do so. The only way to get near 100% cure is to examine all four glands and see how active each one is. Period. One more note folks, "mini" does NOT mean "one-side". Our operations are smaller than anybody else's in the world, and ours are both-sides.
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About 18% of the operations we perform are on people who have had one (or more) parathyroid operations somewhere else that did not cure them (we do 2-4 re-operations daily). Often it is because they had a one side operation that removed a tumor and their labs did not become completely correct afterwards. These folks have a second parathyroid tumor just like this man. Even though the sestamibi scan clearly shows only one parathyroid tumor, up to 15% of people will have a second tumor that does not show up. Only the big tumor shows up on the scan, the smaller tumor is being suppressed by the big one so it doesn't show up. If you don't remove the second tumor it will continue to grow (all tumors do) and become the dominant tumor and these patients are not cured of their hyperparathyroidism. These patients will need a second operation to take out the second tumor. We do NOT perform one-side parathyroid operations routinely--about 99% of the operations we perform are exactly like this--examine all four parathyroid glands quickly and safely. We invented the one-side operation--yet we won't do it any more because even with our experience it simply won't cure some of the patients. If your speak to a surgeon and he/she is going to operate on one side of the neck and then measure your hormone levels to see if you are cured, then write down our phone number--because 15% of you will come here for your second operation.
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The lesson learned here is that sestamibi scans are usually wrong. If they are negative then they are wrong 100% of the time--the patient has a tumor and it is just hiding behind the thyroid and it can't be found. If the sestamibi scan is positive (like it is in this video), then it is wrong about 60% of the time (like it is in this video). Hey! Are you listening?  A negative scan is wrong 100% of the time. A positive scan is wrong about 50% of the time! Stop worrying about the scan! Stop getting scans!
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After you see this video you will understand why we say emphatically that all our patients get a mini-operation. We perform the same mini-operation on patients with a negative scan as we perform on patients with positive scans. This patient is the perfect example, the RIGHT side of his neck had a positive scan and one parathyroid tumor and one small normal gland. The LEFT side of his neck had an excellent quality, perfectly negative scan. The operation we performed on the left side of his neck was exactly like the operation performed on the right side. The scan-negative left side of his neck had a parathyroid tumor and a normal gland--just like the scan-positive right side.  We perform the same mini-parathyroid operation on all people, and those with a negative scan have the same mini-operation that takes the same amount of time as those people with a positive scan. As you can see on the video, the operation on the left side (the negative side) was actually faster than it was on the right side!
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If you think that you are getting a Mini-Parathyroid Operation because your surgeon has seen a positive scan and they will then operate on one side of your neck, then understand that you may need a second operation, as shown in the graph below. If your endocrinologist says "we will get a scan to see if you can have a mini-parathyroid operation", then know your endocrinologist has never seen a parathyroid operation in his/her life because that is not true. Send this video to them. The mini parathyroid operation is dependent on the skill of the surgeons, not the accuracy of the scan. Patients with negative scans and positive scans should have the exact same operation.
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This graph shows the recurrence rates (how often somebody gets parathyroid disease a second time requiring a second operation). The blue line shows that people almost never get parathyroid disease a second time, if your surgeon operates on both sides of your neck and looks at all four parathyroid glands. Said differently, if your surgeon tests all four parathyroid glands, you can be assured you will be cured FOREVER almost 100% of the time.  HOWEVER, if your surgeon operates only on one side of your neck and tells you that he/she has cured you because they successfully removed a parathyroid tumor, then you have a 10-12% chance that you will NOT be cured during this operation. AND, even if you are cured, you have another 10% chance that you will need a second operation in the next 10-15 years because you are like the man in this video who had two tumors and the surgeon only removed the biggest one. Importantly, this means you will never have any of the benefits of the first surgery--you will not feel better, your heart disease will not get better, your osteoporosis will continue to worsen, and your risk of developing several types of cancer will remain high. Dr Norman is the inventor of one-side parathyroid surgery, yet he no longer performs this operation. Fortunately, as you can see from this video, a skilled surgeon can test all four parathyroid glands in less than 20 minutes on almost every patient--even if the scan is negative. Note: this graph comes from an upcoming publication by Drs Norman, Politz, and Lopez: DRAMATIC DIFFERENCES IN LONG-TERM CURE RATES FOLLOWING UNILATERAL VS. BILATERAL PARATHYROIDECTOMY:  AN 18-YEAR, SINGLE-CENTER STUDY IN 16,500 PATIENTS.
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"Geeze Dr Norman, if the scan is so worthless, why do you get one just before your patients go to the operating room?"  Because we use the scan to give us different information! We do NOT use the scan to find the tumor (like your doctor will do). We use the scan to make sure your parathyroid is not in your chest. We use the scan to see if you have a thyroid goiter, or there is a thyroid problem (like a cold nodule) that needs to be addressed while we are in there taking out the parathyroid tumor. We use the scan to make sure your parathyroid tumor isn't in some weird place like under your jaw or next to your heart. We use the scan to make sure there are no "surprises". Therefore, the NEGATIVE information that the scan gives is much more important than showing the parathyroid tumor. Clearly this video shows we have the expertise to find parathyroid glands very quickly and safely. We just don't like surprises! Most of all, however, we use the scan because we need the parathyroid glands to be radioactive so we can use the probe to determine how much hormone each of the parathyroid glands are making (read below). Most doctors get scans so they can "find" the tumor. The scan is not very good at this--even when it is "positive", it will be wrong 60% of the time. Stop getting scans!

During the operation Dr Norman shows a small sponge with a few drops of blood on it. There is no trickery here... parathyroid surgery can and should be virtually bloodless.

We look at all four parathyroid glands in about 99% of parathyroid operations we do. There are some rare exceptions not worth discussing here. If you come to our center for a parathyroid operation, you can expect to have all four of your parathyroid glands examined to see 1) how big they are, and 2) how much hormone they are making. It is simple: the good ones stay in, the bad ones come out. Of our last 10,000 patients, we removed more than 1 parathyroid gland in about 25% of people. That puts them on the blue line in the graph above and keeps them off the red line!
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All four parathyroid glands can be examined for their anatomy and hormone production through a very small incision. This incision is smaller than anybody else in the world makes. We make this same little incision all day long, every day.
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All four parathyroid glands can be examined in less than 10 minutes from the time the operation starts. (Believe it or not, nobody else in the world can do a 4-gland parathyroid operation in less than 1 hour). One of the reasons we made this video is because many surgeons say it is impossible to do a 4-gland parathyroid operation in less than 1.5 hours. Unless they see it with their own eyes, they don't believe that we can do this in less than 20 minutes. This is why we shot the entire video with one continuous filming. There is no editing, and we show the clock many times. No trickery here: a surgeon that does the same operation many times per day for many years gets very, very efficient.
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You can see the pathology report from this operation here: images/VideoPathReport.pdf. It shows that two parathyroid adenomas were removed and two normal glands were identified and biopsied. No trickery here.

The probe is used to measure parathyroid hormone (PTH) being produced from each parathyroid gland. The probe measures the "activity" of any parathyroid gland. This is a 4th generation probe, a probe (and technique) that was invented (and patented) by Dr Norman in the mid 1990's.
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MIRP is an acronym made up by Dr Norman in 1994 which means "Minimally Invasive Radioguided Parathyroidectomy". It means the probe is used to measure hormone production from the parathyroid glands using radioactivity, allowing the surgeon to get almost immediate feedback on the status of the parathyroid glands instead of measuring hormones from the blood (which takes an hour and is not as accurate) or getting frozen sections where the gland is removed and sent to the pathologist who looks at it under the microscope (which is completely stupid and 1945 technology). MIRP surgery has the highest cure rates because the probe assures that normal glands are left in, and all of the abnormal glands are removed. Sounds simple... but if your doctor is not using a probe, this is not happening.
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The probe measures radioactivity. The radioactivity attaches inside the parathyroid cells where PTH is being produced. Thus, the radioactivity contained within each parathyroid gland is equal to the amount of parathyroid hormone that the gland is producing. Parathyroid tumors that are producing lots of hormone become very radioactive. Normal parathyroid glands become dormant (go to sleep) when the calcium is above 10.0 mg/dl, thus normal glands have almost no radioactivity in them. The probe is used to determine which glands are bad (making hormone) and thus need removed, and which parathyroid glands are good (they are dormant and not making hormone) and thus should NOT be removed. During the operation on the video, Rob (one of the assistants) takes the parathyroid samples from Dr Norman and scans them with the probe. The probe is connected to a computer which converts radioactivity into the amount of PTH produced.
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The probe is connected to a computer which calculates the amount of hormone being produced from each gland based upon its contained radioactivity. The operating room staff perform these tasks while the surgeon continues to operate. The amount of hormone each gland is making is recorded and becomes a part of the patient's medical records. This also helps us understand how much calcium each patient will need in the few weeks after the operation. A lot can be learned by knowing what the other parathyroid glands are doing--another reason why we want to see and evaluate all four glands in all patients.
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During the video you can see that the probe takes a measurement of the two tumors, and small pieces of the normal glands. We've measured the amount of radioactivity contained within well over 55,000 parathyroid glands. From these measures we have developed a standard-curve that converts the number seen on the probe into units of parathyroid hormone being produced. The numbers you see on the probe are not the amount of hormone, a computer makes this calculation. You can see the relative values... normal glands contain between 25 and 60 counts of radioactivity, while tumors are over 250 counts. The large parathyroid tumor in this man had about 2200 counts of radioactivity and the second tumor had 539. The computer converted this to 2873 pg/ml hormone production from the first tumor, and 719 pg/ml hormone production from the second tumor (see photo below). The normal parathyroid glands converted to 19 and 21 pg/ml/min, which shows them to be dormant (making almost zero hormone).
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It takes the probe about 2 seconds to measure the amount of hormone being produced from a parathyroid gland. We do not use intra-operative PTH monitoring, which is where the parathyroid hormone in the BLOOD is measured during an operation. That technology takes 45 minutes to know the answer and you have to wait 10-20 minutes after the parathyroid tumor is removed before you can draw the blood. Thus, it takes about 1 hour to perform intraoperative PTH monitoring (every time it is used, and usually surgeons use it multiple times per operation--which is why so many surgeons take 4-6 hours to do a parathyroid operation. We try hard not to poo-poo this technology, because it can help surgeons who don't do this operation very often. But we can tell you this, no expert would rely on intraoperative PTH monitoring. It is a tool for inexperienced surgeons. This is the only place on this 500-page website that we mention this technology. We would never use it because it is wrong 18% of the time and takes 1 hour. We operate on 1-2 people every day who had a one-side operation with the incision placed over to the side because they had a positive scan and their surgeon removed only one tumor and then measured intraoperative PTH levels--which showed a 50% drop in hormone. This is a fine test for non-expert surgeons and it can help them do this operation with an 85-90% cure rate. But, that means we get to remove their patient's second tumor--just like you saw in this video.

If you aren't a surgeon, or don't work in an operating room then a very important aspect of this operation is not being appreciated. Normally (in every other parathyroid operation in the world) the removed tumor and the samples (biopsies) of the normal glands are put into small containers and sent to the pathology department of the hospital so a pathologist can look at the tissue under a microscope. We do not do this. This is called "frozen section" analysis of the tissue. During the frozen section, the pathologist looks under the microscope and then calls the surgeon on the phone (while he/she is still operating) and reports 1) if this is a parathyroid gland or some other tissue (like a lymph node), and 2) if the parathyroid gland is full of lots of parathyroid cells or lots of fat. The concept here is that parathyroid glands full of fat are normal (dormant), and those that are full of lots of cells and little fat are bad parathyroid glands. Unfortunately, this is technology out of 1935 (not kidding), and the normal range for the percent fat is between 30 and 90%. This is absolutely the most ass-backwards thing that surgeons still do. If you want a chuckle, ask your surgeon if he/she is going to "get frozen sections". They will of course say "yes". Then you ask them why and watch them squirm. Ask them "can't you tell its a parathyroid gland and not a lymph node by looking at it?" If they say "not always" then know they are not experts. Do you sometimes not recognize your own kids? Surgeons perform frozen sections to make sure they found a parathyroid gland and not a piece of fat or lymph node. This is just as the old guys did it back in 1955, the old guys who taught these guys. We stand amazed every day that our peers continue to perform surgery like it was 1955.
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Frozen section analysis costs $285 for the first one, and $195 for the subsequent ones (this is what Medicare pays the pathologists). We've seen surgeons get 20, 30, and even 40 of these dumb tests. While we are talking about cost, know that the intraoperative PTH assay discussed briefly above cost about $400, and when surgeons use this method they get a minimum of three, and often about 6. Now you know why our center is a "preferred provider" for parathyroid surgery for Medicare, Blue Cross/Blue Shield, Aetna, Cigna, Humana, etc, etc. We are cheaper for the insurance companies and have the highest cure rate.
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Frozen sections take about 12-15 minutes each (minimum!) once the tissue leaves the operating room. It takes the operating staff at least 2-3 minutes to fill out the paperwork for each specimen before it can even leave the operating room.  Thus, if your surgeon is going to look at all four parathyroid glands, he will absolutely get a frozen section on each one. Now you can see one more reason why most parathyroid operations take 2-5 hours.

All the stitches we use to close the wound absorb in about 1.5 months. They don't exist anymore after that. Note that the stitches used to close the skin are too small to see on the camera (smaller than a human hair). Thus there are no stitches to remove. Look folks, there are still a lot of surgeons out there using staples and ugly nylon stitches to close these wounds. This means that you have to go back to the doctor a week later to get the stitches removed, and it means you get an ugly "rail-road" scar. Ask your surgeon what kind of stitches they use on the skin--if they say you have to come back to the office to get the stitches removed, then get up and run. RUN!  It is not 1965 anymore.
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Bandage: The band-aid we use is a simple steri-strip. You can shower the very next morning and get it wet. Just peel it off in one week. That's it.

The folks that operate with Drs Norman, Politz, and Lopez have been with us for years. These assistants and nurses have performed many thousands of operations with these surgeons. Note that they give the instruments to Dr Norman during the operation without Dr Norman having to ask. They measure the size, weight, and hormone production from the parathyroid tumors that are removed (and the small biopsies of the normal glands which are not removed). Everybody in the operating room does this operation exclusively; they work in our parathyroid center and they don't assist on any other type of operations. Our excellent staff is another reason why we are so efficient. Everybody knows what they are doing and has done it thousands of times before. Also note that there are no surgery residents (surgeons in training) working with us.

This man went home just over one hour after the operation. Most folks stick around about 1.5 hours. Some wake up faster and go home about 45 minutes after the operation while some feel a little punk and stick around 2 hours or so. Less than 1 in 1000 people spends the night with us. If your surgeon says there is a possibility that you may have to spend the night in the hospital, then you can bet your surgeon doesn't perform 20 of these operations per year.