London Thyroid Surgeons

 

A SPECIALIST PRACTICE FOR THYROID & PARATHYROID SURGERY

       Minimally invasive 'keyhole' surgery

Minimally Invasive ‘Keyhole’ Video Assisted Thyroidectomy & Parathyroidectomy (MIVAT & MIVAP)

Minimally invasive ‘key-hole’ surgery is an option for the treatment of both thyroid & parathyroid diseases. 


Minimally Invasive Video Assisted Thyroidectomy (MIVAT)


The surgeon uses a special High-Definition endoscope and video screen to operate on the thyroid (and parathyroid) glands through tiny incisions. An advanced Ultrasonic ‘Harmonic’ scalpel is used to precisely cut and seal blood vessels around the thyroid gland. Most patients after the MIVAT technique have significantly less post-operative pain than after a conventional ‘open’ surgery, less problems with swallowing and they recover much faster overall. Patients often return to work after just 1 week. Most patients are discharged early the next morning and may be performed as a day-case procedure in some cases. The incision is either closed using surgical glue or dissolvable stitches requiring minimal care.


The technique offers several distinct advantages over conventional open surgery including:

  • Small ‘cosmetic’ incision–one inch or less and often invisible.
  • Less pain and swelling
  • Faster recovery & return to work
  • Reduced scarring
  • Patients may be treated as day-case.


Minimally Invasive Video Assisted Parathyroidectomy (MIVAP)


Conventional open (4-gland) parathyroid exploration was the considered the standard of care for treatment of primary hyperparathyroidism until the 1990s, when improvements in imaging techniques made limited (less than 4-gland) exploration feasible. Now, many expert centers worldwide have adopted minimally-invasive parathyroid surgery (MIVAP) as their preferred surgical approach. Research studies suggest that both the conventional ‘open’ & MIP techniques all offer a similarly high success rate (>98%) and low complication rate (about 1%) when performed by experienced surgeons. Only a few surgeons in the UK have completed special training to be able to perform this specialised surgery. Professor Dae Kim completed an Advanced Endocrine Fellowship in Toronto under Professor Jeremy Freeman where he was trained in both complex parathyroid surgery as well as minimally invasive endoscopic surgery (with Intra-operative PTH monitoring). 

Is Keyhole Surgery suitable for me?


The underlying principle behind limited exploration is the fact that approximately 90% of individuals with primary hyperparathyroidism have only one diseased gland. The challenge is then to find the culprit gland successfully prior to operation. The essential imaging techniques used to localise solitary parathyroid adenomas are parathyroid sestamibi (a nuclear medicine test) and ultrasound. If the scan localises to a single gland, then a minimally invasive parathyroidectomy (MIVAP) can be performed where a small 2-2.5 cm incision is made in the central lower neck and the gland is removed.  Whilst still asleep under GA, a special intraoperative PTH assay is used, which will tell us once and for all if we have solved the problem before surgery is over.  In this situation the calcium levels will normalise over the next few days and most patients are discharge the next morning. In fact, in the US and other parts of the world, MIP is performed as a day case procedure leaving the hospital within 6 hours of the operation. 

In addition, patients after this mini-surgery experience less swelling & pain, and much faster overall recovery. The ‘key-hole’ surgery may be performed under local anaesthetic along with medication through an IV to calm you during the procedure. Most patients having surgery under local anaesthetic may return home the same day of the surgery.

What are the benefits of Keyhole?


For localised one-gland disease, we favour the focused lateral mini-incision technique, which involves an incision length of 1.5-2.0 cm. This method provides the most direct access to the diseased parathyroid glands, minimises tissue injury, and has good cosmetic results. Alternatively, for 4-gland exploration, a small 2-3 cm incision is made in the lower central neck in a natural skin crease and a parathyroid exploration is performed to identify all four glands and only remove the problematic gland. If more than one gland is problematic then all which are enlarged are removed. In less than 5% of cases are all four glands problematic, termed parathyroid hyperplasia, and as such 3½ glands are removed and ½ of one gland is reimplanted into one of the central neck muscles for close observation post-operatively.  

These minimally-invasive techniques offers distinct advantages over conventional open surgery including:

  • Less pain and rapid recovery
  • Better cosmesis
  • Most patients discharged within 23 hours following surgery
  • Option to be performed under general anaesthesia or local anaesthesia with IV sedation
  • Provides same excellent cure rates (greater than 96% success) to the conventional open approach.