Thyroid and parathyroid surgery

Surgery of the thyroid and parathyroid is traditionally performed through a transverse cervical incision with very low morbidity and virtually no mortality. However, with the increasing acceptance of minimally invasive surgery, surgeons are now applying these techniques to the cervical region. Several minimally invasive approaches to the neck have evolved over the recent years. Gagner reported the first endoscopic parathyroidectomy in 1996 [i]. Huscher and colleagues followed with the description of complete endoscopic thyroidectomy [2]. With the endoscopic approach, several approaches to the thyroid and parathyroid glands have evolved, including the cervical approach, the transaxillary approach, and the breast or anterior chest wall approach, as well as video-assisted surgery [391. In addition, advances in techniques have allowed surgeons to operate on both the thyroid and parathyroid glands through a mini-open or focused approach [io, ii]. In this chapter, each of these approaches will be described paying attention to their inherent advantages and disadvantages. Of all of these techniques, the focused approach to parathyroidectomy seems to be the most commonly used approach by endocrine surgeons. Surgery of the parathyroid glands has seen a rapid change over the last several years with unilateral neck exploration for primary hyperparathyroidism now the standard approach at most centers. First described in 1982, the focused approach relies on preoperative localization, as well as intraoperative monitoring of parathyroid hormone (PTH) [12, 13]. The controversies that now exist include choice of preoperative localization along with the use of intraoperative PTH assay with and without radioguidance.