Minimal Parathyroid Surgery
The Minimally Invasive Technique Utilizing Intraoperative Nuclear Mapping
Also called: Minimally Invasive Radioguided Parathyroidectomy, or "MIRP" The technique of minimally invasive parathyroidectomy using intraoperative nuclear mapping (also called minimally invasive radioguided parathyroidectomy (MIRP)) was pioneered in
Also called: Minimally Invasive Radioguided Parathyroidectomy, or "MIRP"
The technique of minimally invasive parathyroidectomy using intraoperative nuclear mapping (also called minimally invasive radioguided parathyroidectomy (MIRP)) was pioneered in 1993-95 at the University of South Florida by Dr. James Norman, M.D. During the past several years, the MIRP procedure has clearly become the preferred method of removing parathyroid tumors. More than 120 scientific articles have been published by more than a dozen US universities during this time showing that the MIRP has a higher success rate and lower complication rate than standard parathyroid surgery. This minimal parathyroid surgical technique has gained wide acceptance as the most advanced, least invasive, and preferred method for operating on parathyroids.
The concept of minimally invasive radioguided surgery is simple: about 97% of patients with parathyroid disease have just one bad parathyroid...so give them a very small operation to remove just that one bad gland and leave the other 3 alone. In other words, change the big standard operation into something very small, fast, simple, and much less complicated for the vast majority of patients. The best news is that the cure rates reported to date for the MIRP procedure are as high or even higher than they would be if the more extensive and complicated operation was performed. This operation is possible because of the small probe shown in the picture. This probe will detect minute levels of radioactivity and so the surgeon uses it during the operation to find the hyperactive parathyroid tumor which is very easily made radioactive for about 4 hours with a very small (and very safe) dose of a special drug.
EndocrineWeb now has a complete page of photos illustrating
how MIRP surgery is performed. Click Here
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. This allows the surgeon to operate on one very small area of the neck rather than exposing the entire neck and both sides of the thyroid. If the operation only takes place on one side of the neck, then the risks of damaging nerves and other important structures on the other side of the neck are eliminated and, therefore, the risks of this procedure are expected to be less than half of that seen during a complete neck exploration (all reports of MIRPs in the medical literature have shown a lower complication rate). If you are contemplating parathyroid surgery, ask your doctors about this procedure, you will be glad you did. To see what endocrinologists think about MIRP (an important scientific survey), click here.
Another advantage of the MIRP technique is that it is almost always performed without general anesthesia (put to sleep). The operation is typically performed through a 2.5cm (1 inch) incision (shown in yellow) rather than the usual 14 cm (6 to 10 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 for all four parathyroids to find the one which is overactive. Since the diseased gland is radioactive, the probe is placed into the wound every few minutes to direct the dissection right to where it is hiding. The probe also allows the adenoma to be removed in much less time. DON'T LET YOUR DOCTOR DO THE OLD FASHIONED OPERATION. THE RESULTS ARE NOT AS GOOD, AND THE COMPLICATION RATE IS MUCH HIGHER! KEEP READING!
The average operative time to remove the diseased parathyroid gland using this technique is about 17 minutes as compared to an operation which can take up to three hours (or more!) when it involves exploration of both sides of the neck. Some centers (such as the Norman Parathyroid Clinic) are now reporting that as many as 75% of operations can be performed in under 15 minutes. The ability to do the procedure this quickly means that minimal anesthesia is needed, and unnecessary dissection within the neck is avoided. 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. Most institutions which are performing this type of surgery send virtually all patients home following this procedure (UPDATE: June 2005, Dr. Norman has reported sending 100% of his last 2,000 parathyroid patients home within 2 hours). Even patients over 80 years old have had this procedure and 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 percent, but most expect a long term cure rate of about 98 to 99 percent (Dr. Norman's reported and published cure rate is 99.75% -- remember, the standard operation has a cure rate of about 86 to 95%).
Advantages of Minimally Invasive Radioguided Parathyroidectomy (The MIRP Procedure)
- Local anesthesia or a very light general anesthesia using IV sedation (twilight anesthesia) -- instead of general anesthesia where a breathing tube is put down the throat..
- 3/4 to 1.25 inch incision instead of 4 to 8 inch incision (thin people can expect a 1 inch or even smaller incision).
- Usually less than 30 minutes in the operating room vs. 2 to 5 hours. (average operating time is under 18 minutes)
- No risk to nerves and other structures on the "normal" side of the neck (risk to the voice-box nerve should be less than 1/4 of the risk if performed by the old "exploration").
- Less than 1/4 of the potential complications than the standard operation.
- Much smaller overall operation so less pain (only Tylenol or aspirin needed).
- Return to normal activities usually by the next day (instead of a week or so of recuperation time). Nearly zero recuperation time needed.
- Usually home in an hour or 2 (vs. 1 to 3 days in the hospital).
- Most patients go out to eat the evening of surgery.
- Significantly less expensive than the standard operation. *
- Cure rate significantly higher than the standard operation.
- Dramatically reduced chance of surgery not helping the problem.
- Zero risk of hypoparathyroidism (a rare complication seen when all parathyroids are removed)
* Eight publications in medical journals have now shown that the cost of performing a MIRP is significantly less than the standard operation; as much as 1/3 the overall cost! The most recent one (Journal of Head and Neck Cancer, November 2003) shows it can be about 1/2 the cost of the old fashioned operation)
Who is a Candidate for Minimally Invasive Parathyroidectomy?
This new approach to parathyroid surgery has taken the surgical and endocrinology specialties by storm. The cure rate is significantly higher than any other parathyroid operation and the complication rate is near zero (significantly less than 1 percent when performed by expert parathyroid surgeons). This is changing the way all doctors look at this disease. Since hyperparathyroidism can now be fixed easily for the vast majority of patients in less than 20 minutes, most endocrinologists are sending all of their patients for this minimal operation. They feel it is riskier to wait around and potentially develop osteoporosis or kidney stones than it is to have this procedure. Besides, the operation makes the majority of people feel better and enjoy life more!
This technique is revolutionizing the way parathyroid surgery is performed. 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 has now been proven to be BETTER than the gold standard operation and they are embracing it fully. A recent study of endocrinologists has shown that this minimal parathyroid operation is the preferred method to remove parathyroid tumors. View an abstract of the opinions of nearly 800 endocrinologists surveyed regarding MIRP (click here). * 96% of endocrinologists would travel to another state to have a MIRP by an expert if they needed a parathyroid operation!
Virtually all patients with hyperparathyroidism can have a Mini-Parathyroid operation (MIRP) when performed by one of the few extremely experienced parathyroid surgeons in the world. Those patients in whom a high quality Sestamibi scan shows a single adenoma as the cause for the primary hyperparathyroidism are extremely good candidates for minimally invasive parathyroidectomy, and their operations should be expected to last about 15 - 25 minutes.. About 85 - 90 % of all patients with primary hyperparathyroidism will localize in this manner and can have this very fast out-patient procedure. The other ~ 10 - 15 % will not localize on their Sestamibi (a "negative Sestamibi Scan) and will likely need all four parathyroid glands examined, however, with radioguided techniques (MIRP), this can still be done in under 25 minutes in almost all patients, through the same 1 inch incision. YES, ALL PATIENTS CAN AND SHOULD HAVE A MINI- PARATHYROID OPERATION. YES, ALL PATIENTS, REGARDLESS OF THEIR SESTAMIBI SCAN RESULTS CAN HAVE A MINI OPERATION IF THEIR SURGEON KNOWS HOW TO DO IT ! You may be better served by finding an expert. As you will read on other pages of this website, there is no other operation that is more dependent upon the experience of the surgeon. Parathyroid surgery is all about experience, so shop for your surgeon very smartly!
Read what patients say about having a MIRP mini-parathyroid operation. These are patients just like you who never heard of a parathyroid gland until they got this disease. They don't know anybody else who has had this disease, and their doctor doesn't see to much of it either. Read about patients who have had their entire problem cured in 30 minutes or less! CLICK HERE.
Has This Technique Been Published?
This is a frequently asked question, and it should be! Physicians have long believed that new medical procedures / drugs should be studied scientifically and subjected to critical review by other physicians and experts in the field. The answer to this question is YES. So as not to clutter up this page, we put this information on another publication page.
We are often asked "If this is the best way to do parathyroid surgery, then why doesn't every surgeon do it this way?" Well, there are several reasons: Since this is a rare disease and most surgeons see only one case of parathyroid disease every year or two it doesn't make economic sense for the hospital to purchase the equipment.. Typically, the radioguided probe will cost $150,000 and this is simply too much if it is to be used only once or twice per year. Secondly, the surgeon is required to take a training course to use radioguided techniques in the operating room. These courses are expensive, and require the surgeon to miss 2 days of work. Again, it is not economically sound for a surgeon to do this if he/she only sees 1 or 2 patients per year with this disease. Finally, the surgeon has to take courses and yearly updates on using radioactive materials. This can be a big pain in the rear! It all comes down to economics and experience. If the patients are not demanding radioguided surgery, and the surgeon / hospital are not performing more than a dozen or so parathyroid operations per year, then it doesn't make economic sense to perform radioguided parathyroid surgery.
The biggest reason that all surgeons don't do mini-parathyroid surgery, however, is because this is a rare disease. It is un-real to expect every surgeon to be an expert for a rare disease. In fact, if you think there is a parathyroid expert in every large city, you are wrong. There cannot be an expert in every city for a rare disease. Every surgeon gets to do 0 to 2 parathyroid operations per year... hardly enough practice to be an expert. Why do they do it then??? Because it is a tricky operation it pays very well. Your general surgeon won't say no to you... there is too much money involved.