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SURGICAL PICTURE OF PARATHYROID ADENOMA (MIRP & MIVAP)
Parathyroid Adenoma in minimally invasive radioguided parathyroidectomy (MIRP)
This patient presented with hyperparathyroidism.  A positive Technetium 99m-Sestamibi scan showed a right inferior parathyroid adenoma.  Using the Neoprobe, the location of the adenoma was marked on the skin prior to the operation.  To help visualize the adenoma, an intravenous infusion of methylene blue was administered. This dye is known to stain the parathyroids with a deep blue color.  A small 4 cm-incision was made just above the right clavicle. The right sternocleidomastoid muscle was retracted.  The sternohyoid muscles were separated in the midline and retracted.  The dark blue adenoma immediately came into view, inferior to the right thyroid lobe and lateral to the trachea.
Parathyroid Adenoma
Magnified picture of the adenoma shown above.  Note the blue color from the methylene blue infusion. This adenoma weighed 350 mg (Normal parathyroid glands weigh 30-40 mg).
Parathyroid identification by methylene blue infusion.
Aust N Z J Surg. 1978 Jun;48(3):314-7.
Bambach CP, Reeve TS.

A preoperative infusion of methylene blue was employed in 20 patients undergoing neck exploration for hyperparathyroidism. The dye was noted to stain adenomas and hyperplastic glands a deep purple-blue colour. Normal parathyroid tissue stained to a lesser extent or not at all. All unstained parathyroid tissue was normal histologically. Methylene blue infusion is a safe method of more rapidly identifying parathyroid tissue. Its preferential staining of abnormal parathyroid tissue can assist the surgeon in deciding the extent of his parathyroid excision.


For a couple of days after surgery, patients who have received methylene blue to localize the parathyroids, will continue to notice  a bluish green discoloration of the urine.  Although methylene blue has been successfully used for more than 30 years in parathyroid surgery, there are some extremely rare side effects that could happen from the administration of this dye.  These include confusion, hallucinations and abnormal limb movements that may last a few days before slowly subsiding. 

OTOLARYNGOLOGY HOUSTON

Bechara Y. Ghorayeb, MD

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Outpatient Minimally Invasive Endoscopic Video Assisted (MIVAP) or
Radioguided (MIRP)
Parathyroidectomy - Outpatient Procedures
What is a Sestamibi Scan?
Technetium 99m-Sestamibi is a protein that is labeled with radioactive technetium (Tc99).  It is injected intravenously for diagnostic use. The precise structure of the technetium complex is Tc99m[MIBI]6+ where MIBI is 2-methoxy isobutyl isonitrile.  Tc99m decays by isomeric transition with a half-life of 6.02 hours.
MIBI (2-methoxy isobutyl isonitrile) accumulates in both the thyroid and parathyroid glands.  Tc-99m MIBI is sequestered within the mitochondria. The parathyroid glands accumulate the radioactivity and retain it longer than the adjoining thyroid gland. A gamma ray detector similar to a Geiger counter is used to pick up radioactivity at various intervals.  Initial images show normal diffuse uptake by the thyroid gland, while delayed images show a persistent activity in the parathyroid glands.
 
Since normal parathyroid glands are inactive and do not produce parathyroid hormone when there is high calcium in the bloodstream, they do not take up the radioactive particles. The parathyroid adenoma, however, remains active and produces excessive amounts of parathyroid hormone.  Because it has large numbers of mitochondria per cell, the adenoma accumulates radioactivity and shows conspicuously on delayed images.  The three other parathyroids do not show on the scan or appear very faint, compared to the adenoma.  This is why the Sestamibi parathyroid scan will point to the adenoma with 90% accuracy.

CLICK PICTURE
Left lower parathyroid adenoma.
Endoscopic parathyroidectomy
(MIVAP)
What is Radioguided in MIRP? Radioguided parathyroidectomy utilizes the above principles to help the surgeon find the adenoma.  An appropriate dose of Tc99m-Sestamibi is injected intravenously, about two hours prior to the operation.  By this time, the radioactiviy has already washed out from the thyroid gland and has concentrated in the parathyroid adenoma.  A pencil-like gamma ray detector probe is placed on the neck before making the surgical incision.  It will show a higher radioactivity over the adenoma, compared to the rest of the neck.  This eliminates the guesswork and allows the surgeon to make a much smaller incision, right on top of the parathyroid adenoma. 
The same probe is the covered with a sterile sheath and used to point to the adenoma inside the wound.  When the adenoma is found and removed, the radioactivity inside the wound drops, while the removed adenoma still registers high radioactive levels.
About 1.5 to 2 inch-incision instead of 3 to 6 inch-incision.

Usually less than one hour in the operating room instead of 1 to 2 hours.

No risk to laryngeal nerves and other structures in the opposite side of the neck.

Less complications than the standard operation.

Much smaller overall operation, therefore, less pain.

Return to normal activities usually by the next day.

Usually performed on an outpatient basis.

Cure rate as high or higher than the standard operation.

Could be performed under local anesthesia instead of general anesthesia.
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