Babak Larian, MD, FACS, is known around the world for his parathyroid expertise and frequently has patients fly in from out of town for consultations and surgery at the CENTER for Advanced Parathyroid Surgery.
Dr. Babak Larian of the CENTER for Advanced Parathyroid Surgery provides an overview of Minimally Invasive Parathyroidectomy. It can be performed under local anesthetic in under 20 minutes with a small incision requiring minimal recovery time.
Minimally Invasive Parathyroidectomy (MIP), or minimally invasive parathyroid surgery, has become the preferred method of operation for the parathyroid glands, and it is something all patients considering standard parathyroid surgery can have.
There are several advantages with the Minimally Invasive Parathyroidectomy. First off, we know with a very high degree of accuracy where the tumor is located prior to surgery. A positive sestamibi parathyroid scan along with an ultrasound that both show the same location for the abnormal gland is usually a very accurate way of confirming the location. This, in turn, allows us to operate on one very small area of the neck as opposed to dissecting all of the neck structures in an attempt to locate the bad gland. Naturally, operating on a smaller area of the neck limits the potential risks of the minimally invasive parathryoid surgery.
Because we do not have to search the entire neck, the procedure involves a very small incision in order to take out the bad parathyroid gland. This also means you can undergo the operation as an outpatient, with local or very light anesthesia that enables you to go home the very same day. In fact, the procedure will rarely require general anesthesia.
The quickness of minimally invasive parathyroid surgery does not only mean minimal anesthesia and avoidance of unnecessary dissection, but little operative time as well. Using this technique, the average operative time is less 20 minutes, which can be compared to the standard parathyroid surgery that takes two hours or more. Thanks to the advantages of Minimally Invasive Parathyroidectomy, almost all patients are sent home within an hour or two of the operation.
Most importantly, the complication rate is less than half compared to the standard option.
All patients scheduled for surgery must have the following tests done at the facility of their choice up to 1 month before their planned surgery:
The Day of Surgery
Please plan to arrive at La Peer Surgery Center or Cedars-Sinai Medical Center 2 hours prior to your surgery time. You will be called by the hospital or surgery center to confirm your surgery on the day prior to your surgery. If they have not called by 4:30 pm that day, please call our office.
Do not eat after midnight before your planned surgery. You can have clear liquids up to 8 hours before surgery. You may take your usual asthma, heart, blood pressure or seizure medication with a small sip of water that morning, unless otherwise advised. Please do not take any aspirin or other over the counter pain medications for one week before your surgery. You may use Tylenol in the week before surgery. If you are a diabetic, consult with your physician before taking your medication.
If you develop a cold, sore throat, fever or any illness, please call your surgeon's office prior to your surgery. If you need parathyroid surgery, it is important to know what to expect. The following are some of the most frequently asked questions:
What type of anesthesia will I have?
You are given the option of either general anesthesia or local anesthesia. Most surgeries are done under local anesthesia, during which your neck area is numbed, mild sedatives are given to reduce anxiety, and you are sedated but breathing on your own during the operation. With general anesthesia you are completely asleep and have a breathing tube during the operation.
How long will I be hospitalized?
Most patients are released to go home after surgery. In rare cases, when the patient has other medical issues or the elderly may stay in the hospital overnight.
Will I have pain after the operation?
When the surgery is done under local anesthesia the pain is minimal. Most patients take Tylenol® to keep themselves comfortable at home.
What are the advantages of the minimally invasive thyroid surgery?
The main advantage is less trauma to the tissue, thus you have less pain and recover faster. Additionally the incision is much smaller.
How big is my incision?
1.5 centimeters, or 2/3 of an inch.
Will I have a scar?
Yes. All surgery causes scarring, and how the patient scar is dependent on the individual. However, there are some techniques that we use to minimize scarring. These techniques include: smaller incision size, careful incision placement, and hypoallergenic suture material (to avoid inflammation). As a general rule, it is unusual for adults to have a noticeable scar after a few months. We will discuss with you what creams to use after surgery to improve the healing.
What is the purpose of the pre-surgery tests such as Sestamibi and Ultrasound?
The location of the 4 parathyroid glands can be very unpredictable, and can be at times as high as the upper neck and as low as the chest. These tests, although not perfect, can help direct us to the parathyroid gland that is malfunctioning; they allow us to perform minimally invasive surgery.
When will I know the findings of the surgery?
During the operation, your surgeon will consult with the pathologist who will provide a preliminary diagnosis; as well as performing rapid intra-operative PTH testing. So immediately after surgery your surgeon can tell you about the success of surgery.
Will I have stitches?
Absorbable stitches are used under the surface that do not need to be removed. The incision will then be covered with a tape, which is waterproof so that you can shower as usual (but do not submerge the incision for 7 days). The tape is removed 4 days later, after which antibiotic ointment (any over the counter brand) should be applied to the wound for the next 5 days to improve healing.
Will I have any physical restrictions after surgery?
Swimming is the only major restriction. In general, your activity level depends on the amount of discomfort you experience. Many patients have resumed golf or tennis two weeks after the operation. Most patients are able to return to work within the first week, and you are able to drive as soon as your head can be turned comfortably (this limitation is for driver safety).
What are the complications and possibilities unique to parathyroid surgery?
In about 1 in 150 parathyroid operations, the nerves that control the voice are affected. When this occurs, the main difficulties are projection of the voice and production of high-pitched sounds. It is usually described as hoarse, but will not necessarily be considered abnormal by strangers. Usually, voice changes are temporary, so the voice will return to normal within a few weeks; permanent change is rare.
In a minority of cases, the malfunctioning gland may not be identified during surgery. Under these circumstances the high calcium levels will persist.
In cases where all four glands are malfunctioning, three and a half glands are removed and half of one gland is left behind; it is possible that it will take an extended period of time for it to start working or that it may not ever work adequately. In which case calcium and vitamin D supplementation is needed for an extended period of time.
In rare cases, the gland or glands that remain may later in life start to malfunction and have to be removed.
Some of these possible complications are directly related to the operative experience of the surgeon. Although the risk of these complications cannot be eliminated entirely, they can certainly be minimized in the hands of an experienced parathyroid surgeon performing minimally invasive parathyroid surgery.
Chief of Head & Neck Surgery at Cedars-Sinai
Assistant Clinical Professor of Surgery at UCLA
By Babak Larian, MD FACS Privacy Notice © 2013 Babak Larian, MD FACS. All Rights Reserved.
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