Minimal Parathyroid Surgery

Text and photos courtesy of James Norman, M.D. and the Norman Parathyroid Clinic

How Minimally Invasive Parathyroid (MIRP) Surgery Works

Step 1.  Make the overproducing parathyroid gland radioactive so it can be differentiated from all the other structures in the neck. The key to the success of this technique was the development of the Sestamibi scan in the early 1990's which makes only parathyroid tumors radioactive...normal parathyroid glands will not become radioactive. An example is shown on the right, note that there is only one radioactive (bright yellow) spot in this patient's neck. This test has now become an extremely dependable tool for all patients with parathyroid problems. A high quality Sestamibi scan allows the surgeon to identify which of the parathyroid glands are diseased prior to the operation. The patient is given a very small dose of a radioactive material which is collected in overactive parathyroid glands. Normal parathyroid glands will not absorb the radioactive material and, therefore, do not become radioactive.

Step 2. Operate only where necessary. Now that the surgeon knows which general area of the neck to operate upon, he/she can make a much smaller incision and only operate in a small area of the neck.  The old standard operation requires a neck incision 6 to 8 inches in length (not shown). The picture on the left shows the 1 inch incision in the lower neck which is typically made for the minimal parathyroid operation (MIRP). The patient's head is to the top of the picture and a blue pen was used to mark the outline of her collar bones and the top of her breast bone (the sternum). Now its easy to see how this small operation can be performed using only local anesthesia rather than putting the patient asleep under general anesthesia. Note: even when undergoing the operation under local anesthesia, the anesthesiologist will give the patient a bit of sedative medications through their veins so the patient really won't be aware what is going on and almost always they don't remember the procedure.

Step 3. Use a miniature hand-held radiation detecting probe to find the radioactive parathyroid.   Next, the surgeon places a miniature probe into the wound. This probe will make noise when it is placed near the parathyroid because it detects radioactivity similar to a Geiger counter. The probe shown here is made by US Surgical Corporation (Norwalk, CT) and was designed and patented by Dr. Norman. Since the radioactivity only lasts 2-4 hours, the operation needs to be completed during this period of time. By placing the probe into the wound and following the radioactivity, the dissection leads directly to the radioactive gland. The picture on the left shows the probe (wrapped in a sterile plastic cover) being placed into the small wound so the surgeon knows where the radioactive parathyroid tumor is located. What Dr. Norman discovered is that this parathyroid tumor can be found very easily using the probe, so that the entire operation can be performed through a 1 inch (or less) incision in an average of under 25 minutes.  The old way of operating throughout the entire neck of all patients with this disease is giving way to this much improved minimal operation for the majority of patients.

Step 4. Remove the radioactive parathyroid tumor. The next step is for the surgeon to dissect the overactive parathyroid tumor away from the rest of the neck structures and remove it. In this picture we put yellow dots around the parathyroid tumor to make it easier to see. This overactive parathyroid was about the size of a large black olive which is fairly typical. Remember, they are supposed to be the size of a pea or smaller. Parathyroids only have a single small artery and vein. This picture shows Dr. Norman putting a metal clip on the artery and vein prior to removing the enlarged parathyroid.

Step 5. Measure the radioactivity in the parathyroid tumor to help make sure that the patient is cured of their disease.  Once the enlarged parathyroid is out, the probe is placed on it to make sure that the radioactive tumor has been removed. The amount of radioactivity contained within the gland helps the surgeon be confident that the operation is complete and whether or not another "normal" gland will need to be dissected out. Usually it is not necessary to find any other parathyroid glands, but the experience of the surgeon will determine whether more operating is needed or not. The picture on the right shows several things: First, it shows a patient's sestamibi scan on the left side and predicts a tumor in this patient that would be cylindrical and about 1.5 inches in length. Second, it shows the tumor sitting on a blue towel after it has been removed from the patient. The scalpel next to it helps show that the parathyroid tumor is the exact size that the scan predicted. This tumor was removed during an operation which took 18 minutes and the patient left the hospital in time to go out for lunch with her children.

Step 6.   Put on the bandage and get ready to go home. Because the MIRP operation can usually be performed quickly with very limited dissection, patients are quite anxious to go home.  That is fine and they can return to normal duties as soon as they wish (usually the next day). The bandage should be kept dry for about 48 hours, then the patient can shower. The bandage should be left in place about a week. No laboratory tests are required for the vast majority of patients for about a week or two. Of course, this and all of the other decisions and treatments discussed on this page will be up to your doctors...they key is to treat every patient like an individual...each has a special case and special needs.  Your case may be different depending on MANY variables, so discuss all of this in detail with your surgeon and work with him/her so you get what is best for YOU.

Note that this information and the photos were very kindly provided by Dr. James Norman as an educational tool. This procedure works for virtually all patients with primary hyperparathyroidism. Dr Norman performs nearly 800 mini-parathyroid operations per year!. Nearly all operations are completed in under 25 minutes, with the average time being about 17 minutes. Virtually all patients go home one hour after the operation.

You need to be aware...the treatment of parathyroid disease is NOT as invasive or as big an operation as it used to be...and your doctor may NOT be up to date on all the new techniques available. If you want your doctor to talk to Dr Norman on the phone, click here and find the contact information and Dr Norman will be glad to discuss your case with your doctor. 

On June 14, 2005 Dr James Norman performed a MIRP mini-parathyroid operation LIVE over the Internet. Over 17,500 people watched this surgery LIVE as it happened.  This 1 hour program (including a short lecture by Dr Norman) is still available for you to watch. CLICK HERE to be taken to the site where this movie is located and you can watch a mini-parathyroid operation exactly as it happened without any editing.

Important: Please understand the difference between the old fashion surgery performed by general surgeons and Minimal Parathyroid Surgery which is being performed by some specialists. The new procedures have a much higher cure rate and a much lower complication rate (near zero). The operation is smaller, quicker and much safer than the standard operation performed by general surgeons. Please educate yourself and discuss this with your doctor!  NOTE: If your doctor is not aware of these new procedures, Dr. Norman will be glad to discuss it with him/her and see if this is an appropriate procedure for you.  Click Here to go to the phone number page for the Norman Parathyroid Clinic.

• More about Dr. Norman and the Norman Endocrine Surgery Clinic
• More on Minimally Invasive Radioguided Parathyroidectomy (why it was developed)
• Read what endocrinologists think about the MIRP (minimally invasive radioguided parathyroid operation)
• Introduction to Parathyroids and more information on Normal Parathyroid Function.
• More about Hyperparathyroidism and how to Diagnose and Treat it.
• More about the Standard Technique for Parathyroidectomy.
• Where do parathyroids come from?...and why can they be hard to find?
• Overview of the tests often used to find which parathyroid is overproducing hormone.
• Osteoporosis and the effect of parathyroid disease on bone strength.
• More about Sestamibi Scanning.
• When and how to perform SPECT Scanning. technical page.
• View a 3-D rotational SPECT Scan Video.