Mini-parathyroid surgery has become the preferred way to treat parathyroid disease. This is the second page on mini-parathyroid surgery--discussing how MIRP mini parathyroid surgery is performed. MIRP mini surgery is also called "radioguided parathyroid surgery", as discussed below. There are two keys to mini parathyroid surgery: 1) The surgeon should have a good idea which parathyroid gland is bad BEFORE operating  and 2) the surgeon uses a special probe in the operating room that can detect which parathyroid gland is bad, which parathyroid glands are normal, and where each of these parathyroid glands are located in the neck.  Importantly, the standard parathyroid operation does not do either of these two important steps, rather the old way simply requires the surgeon to dissect all parts of the neck and "explore" for the parathyroids, hoping to find one that is big so it can be removed. The probe can tell the difference between a normal parathyroid gland and a diseased gland, so normal glands are not removed.... and the surgeon knows when the patient is cured by removing a parathyroid tumor that is making LOTS of hormone. The probe tells the surgeon when the bad gland has been removed, and it prevents the removal of normal glands.

As developed by Dr James Norman (at the University of South Florida in Tampa) in the early 1990's, the radioguided mini approach to the parathyroid gland has now been shown to 1) have the highest cure rate of all parathyroid operations, 2) have the lowest complication rate of all parathyroid operations, 3) require the smallest incision and least amount of dissection, 4) is able to be performed under local anesthesia or "Light Anesthesia", 5) cost significantly less than other parathyroid operations, 6) require the least amount of time in the hospital of all parathyroid surgeries (about 1.5 hours), and 6) has a lower complication rate compared to a standard parathyroid operation.

NOTE: MOST experts believe that ALL patients should be evaluated for a mini-parathyroid surgery BEFORE they decide how to treat their parathyroid disease! In other words, all patients should discuss mini-parathyroid surgery with their surgeon to see if this option is possible. Also note that a few expert surgeons can perform mini parathyroid surgery on ALL patients, regardless of scan results, and regardless of the presence of co-existing thyroid disease. (Read how 96% of endocrinologists would have the MIRP mini parathyroid surgery if they had parathyroid disease). If your doctor cannot give you a 95% guarantee that your operation will be a mini-operation, then you may want to go somewhere else. If your doctor says you can't have a mini-operation because your scan is negative, you may want to go somewhere else.

How Minimally Invasive Parathyroid (MIRP) Surgery Works

Step 1.  Make the over active 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 for about 3-4 hours...normal parathyroid glands will NOT become radioactive (normal glands are asleep, and thus they don't absorb the radioactive dye). This simple technique requires the patient to be given a very small dose of the same drug that is used to examine the heart during heart stress tests. Using special techniques, the bad parathyroid gland will show itself to the surgeon, so the surgeon does not have to look at all four glands. Thus, a very small operation can be performed that is directed only at the bad parathyroid gland, leaving the normal parathyroids alone.

An example of a Sestamibi scan with a HOT parathyroid gland is shown above on the left.  Note that there is only one radioactive (bright yellow) spot in this patient's neck. This is the overactive parathyroid tumor! 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 with a fairly high degree of certainty which parathyroid gland is diseased prior to the operation. The very small dose of radioactive material is collected in the overactive parathyroid gland. Normal parathyroid glands become dormant when the calcium is high, thus normal parathyroid glands will not absorb the radioactive material and, therefore, do not become radioactive. THUS, a surgeon trained in radioguided surgery can use a special probe to detect which parathyroid is over-producing PTH (the bad gland that has formed a tumor), and which glands are normal.

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 picture on the left shows the 3/4 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 it's easy to see how this small operation can be performed using only local (or twilight) 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 they NEVER remember the procedure. Read more about anesthesia for MIRPs below. REMEMBER, the old-fashioned standard operation requires a neck incision 6 to 8 (or even 10) inches in length (click here to see a picture of the old parathyroid incision). 

Step 3. Use a miniature hand-held radiation detecting probe to find the radioactive parathyroid.   The really neat thing about this procedure is that the parathyroid tumor is radioactive for about 3 hours...so the surgeon can find it if he/she has a probe that can detect it!  So, the surgeon places a miniature probe into the small wound. This probe will make noise when it is placed near the diseased parathyroid gland 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 3-4 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 20 minutes. (August 2006 Update: Dr Norman's average operating time is less than 17 minute for his past 4000 operations). The old way of operating and dissecting throughout the entire neck of all patients with parathyroid disease is giving way to this much improved minimal parathyroid operation for ALL patients. Note... this still lets the surgeon examine the bad glands. And, YES, an experienced parathyroid surgeon can see ALL FOUR parathyroid glands using an incision that is 1 inch or less (slightly bigger in patients over 250 pounds).

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, a normal parathyroid gland is supposed to be the size of a pea or grain of rice. Parathyroid glands only have a single small artery and vein. This picture shows Dr Norman putting a very small clip on the artery and vein prior to removing the enlarged parathyroid. If you haven't seen our page of pictures of parathyroid tumors that were removed from patient's necks, you need to see that page soon... Click Here to see pictures.

Step 5. Measure the radioactivity in the parathyroid tumor to help make sure that the patient is cured of their disease. The most important aspect of radioguided parathyroid surgery is one that most surgeons who have not been trained in this technique miss (and it has us very frustrated!). The probe is not just used to help find the tumor, it is used to determine how much hormone the tumor (or ANY parathyroid gland) is producing. Since the object of the operation is to remove the source of excess parathyroid hormone production, the probe can be used to determine the difference between an adenoma, a hyperplastic parathyroid gland, and a normal parathyroid gland.... Once the enlarged parathyroid gland 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 any other parathyroid glands will need to be dissected out... or even removed. Performed correctly, this method is much more accurate than measuring PTH levels during the operation (over 99% accuracy!). Using all of this information, the experience of the surgeon will determine whether more operating is needed or not. Typically, at least one more parathyroid gland is inspected visually and its radioactivity measured, while the other two are probed with the probe (without dissecting them). Remember... if a parathyroid gland is radioactive it is a bad parathyroid because normal parathyroids don't make hormone and thus don't get radioactive. 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 14 minutes and the patient left the hospital in time to go out for lunch with her children. She was cured of her parathyroid disease this quickly!

Step 6.   Put on the bandage and get ready to go home. Because the MIRP mini-parathyroid operation can usually be performed quickly with very limited dissection, patients are quite ready to go home within an hour or so.  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 24 hours, then the patient can shower and do anything they want. 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...the 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.

The typical MIRP operation at the Norman Parathyroid Clinic:
Updated: 01/14/2009

Frequently Asked Questions About MIRP Parathyroid Surgery
and Mini Parathyroid Surgery

1. What kind of anesthesia will be used for a mini-parathyroid surgery?
   There are several choices for anesthesia for MIRP parathyroid surgery. You should expect either local anesthesia (with IV sedation) or a very light general anesthesia. Dr Norman uses LMA anesthesia almost exclusively--this is not endotracheal general anesthesia and does not require a breathing tube down your throat (trachea), nor does a machine have to breath for you. It simply provides anesthetic (sedative) drugs in your veins and occasionally a small amount of anesthesia gas through a mask. Patients breathe for themselves, but don't feel or remember anything. They wake up within 5 minutes or so, and can be ready to leave the hospital in about 1 to 1.5 hours.
   

2. My sestamibi scan is negative, can I still have a mini-parathyroid operation?
   Most sestamibi scans are performed by radiology departments that only do a few scans per year... and their scans are terrible. Some places that do Sestamibi scans frequently have terrible (worthless!!) scans.  DO NOT let the fact that you have a negative scan preclude you from having a mini-parathyroid operation!!! Do not let your doctor tell you that you are not a candidate for mini-parathyroid operation based upon a negative scan... it's not that simple!  Virtually ALL patients with hyperparathyroidism can have a MIRP mini-parathyroid operation if your surgeon is an expert in parathyroid surgery. Dr. Norman does mini operations on 100%. Over 75% of patients we operate on have a NEGATIVE scan done somewhere else before coming here.
   

3. What is the recovery period? When can I go back to 'normal' activities?
   Patients who have a mini-parathyroid operation (a MIRP) should expect to have dinner with their families the evening of surgery, and go back to work the next day. If your surgeon tells you that you will need a week or two of recovery time from parathyroid surgery, this is a sign that he/she does not do much parathyroid surgery. If you are told this--you may want to find another surgeon who is more up to date. It is simply NOT true! Remember, recovery from surgery involves many factors... one is the health of the patient, but the duration of the operation, the amount of anesthesia given, the size of the wound, how much tissue is dissected inside the neck, how much tissue has to be sewn back together, etc, etc, all play a part in how patients feel after the operation. As a general rule, big operations take people longer to get over than small operations. It's true for gallbladder surgery, hernia surgery, and parathyroid surgery.
   

4. What about stitches? Tell me about the wound.
   Most surgeons who do mini-surgery of all types understand that scar size and wound care are important issues.  Mini-parathyroid operations should be closed in a 'plastic' surgery type of closure with all the stitches on the inside. This has the highest chances of a nice thin scar, and the patient doesn't have to worry about having the stitches removed...they all dissolve in a few weeks when the wound is healed. The wound simply needs to be kept dry for 24 hours and then the patient can shower and even swim. We tell our patients they can shower the next morning. The bandage is only 1 inch long (or less) and 1/4 inch wide. This should be one of the things your surgeon discusses with you before the operation.
   

5. How big will my scar be?
   This is almost entirely dependent upon the skill of your surgeon. The size of your incision should have nothing to do with your sestamibi scan or ultrasound results. The size of the incision is slightly dependent upon the size of the patient. Here you see two pictures. The picture on the left is a woman that weighs 115 pounds. The second picture is a man that weighs 245 pounds. Both have had MIRP mini-surgery performed by Drs Norman and Politz in January 2009. The woman's scar is 3/4 inch. The man's scar is 1 inch. We use a small incision on 100% of patients, even those with a negative scan. Did you see the size of the scar when a surgeon does the "exploration" surgical method?

6. Do you have information written BY PATIENTS who have had mini-surgery?
   Most patients feel alone when they are told they have parathyroid disease. They have never heard of parathyroid glands, don't know what they do, and don't know anybody else that has had a parathyroid gland problem. Click here to read about people just like you who have undergone a MIRP mini-parathyroid operation.

7. Do you have pictures of parathyroid adenomas (parathyroid tumors) removed from patients with hyperparathyroidism? Yep, CLICK HERE to see lots of pictures. This is our newest page!

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