Minimal Incision Parathyroidectomy: Cure, Cosmesis, and Cost

The goals of operative treatment of primary hyperparathyroidism are (1) cure; (2) minimal invasion; and (3) cost‐effectiveness. The optimal strategy is controversial. Retrospective review of was undertaken 66 previously unoperated patients having minimal‐incision, full‐neck exploration by one surgeon over 29 months. A group of 51 women and 15 men had open full neck exploration under general anesthesia through a small (25–40 mm) incision using specifically selected instruments; patients remained hospitalized overnight. Preoperative sestamibi scans were obtained before referral for 17 patients: 11 had localized disease, and 6 did not (65% sensitivity). Four parathyroid glands were identified in 98% of patients; intraoperative frozen section was used selectively on a median of one gland per patient. About 76% of patients had single‐gland disease, 6% had two‐gland disease, and 18% had four‐gland hyperplasia. One patient had four normal cervical parathyroid glands and an aortopulmonary window parathyroid adenoma resected at thoracotomy 1 week later; preoperative sestamibi scans failed to localize his disease. There were no nerve injuries and a 98% cure rate after initial cervical exploration. Excluding the cost of the sestamibi scans, there was no difference between those who had preoperative localization and those who did not; 60% of hospital costs were operating room time‐related. Minimal‐incision parathyroidectomy is effective for curing hyperparathyroidism and has excellent cosmetic results with negligible scar. Preoperative sestamibi scanning had no impact on cure or treatment costs. Strategies to improve cost‐effectiveness must address the substantial costs of anesthesia and operating room services.