With improvement in both preoperative parathyroid tumor identification and the use of intraoperative parathyroid hormone assay, minimally invasive parathyroidectomy (MIP) is now performed more frequently in patients with primary hyperparathyroidism (pHPT). Still, many institutions are not familiar with performing MIP under regional or local anesthesia. Here, Dr. Tobias Carling presents an MIP performed under local cervical block anesthesia on a patient with pHPT and parathryoid adenoma.
In this case, Dr. Tobias Carling and Dr. Courtney Gibson at Smilow Cancer Hospital at Yale New Haven perform a TOETVA on a 45-year-old patient who presented with a growing thyroid nodule that was shown to be a Hurthle cell neoplasm on fine-needle aspiration.
Numerous minimally-invasive approaches to thyroidectomy have been developed over the years to minimize the neck surgical scar, many of which are performed using endoscopic or robotic assistance. However, a more diminutive anterior cervical scar still remains a problem for some patients, as well as more extensive dissections for remote access operations. Therefore, natural orifice surgery was adopted at select institutions in an effort to perform a truly scarless thyroidectomy. Trans-oral endoscopic thyroidectomy has been the latest approach developed, known as the natural orifice transluminal endoscopic thyroidectomy, which is categorized as a natural orifice transluminal endoscopic surgery (NOTES) procedure. There are several ways to perform the natural orifice transluminal endoscopic thyroidectomy. Here, the authors present the TOETVA under general anesthesia.
Tobias Carling, MD, PhD, FACS Yale School of Medicine
Cortical-sparing adrenalectomy allows for the resection of adrenal tumors while preserving unaffected adrenal tissue to prevent adrenal insufficiency. This is especially important in patients with bilateral adrenal tumors, typically pheochromocytomas.
Posterior retroperitoneoscopic adrenalectomy (PRA) allows for a minimally invasive approach to adrenal gland resection compared with the more traditional laparoscopic transabdominal adrenalectomy and open approaches. This approach is ideal to address patients with bilateral disease and was used in this case of a 31-year-old female patient presenting with bilateral pheochromocytomas in the setting of multiple endocrine neoplasia 2A syndrome and coexisting medullary thyroid carcinoma of the right thyroid lobe. A close review of her imaging demonstrated normal-appearing adrenal cortex tissue on the right side that allowed for cortical-sparing adrenalectomy on that side.
Tobias Carling, MD, PhD, FACS
Associate Professor of Surgery
Yale School of Medicine
Taylor C. Brown, MD, MHS
Fellow, Endocrine Surgery
Yale School of Medicine
In this case, Dr. Carling at the Smilow Cancer Hospital at Yale New Haven performs a bilateral retroperitoneoscopic posterior adrenalectomy with cortical sparing on the right side on a 31-year-old female with bilateral pheochromocytoma in the setting of MEN2.
Raj Ayyagari, MD
Assistant Professor of Radiology and Biomedical Imaging
Yale School of Medicine
Fabian Laage-Gaupp, MD
Yale School of Medicine
Paul Irons and Dennis A. Barbon Frank H. Netter, MD School of Medicine at Quinnipiac University
In our second interventional radiology video article, Dr. Raj Ayyagari at Yale New Haven Hospital performs a prostatic artery embolization on a patient with an enlarged prostate who also presented with hematuria. This procedure is appealing because it is less invasive and carries fewer risks than other treatment options.
Tobias Carling, MD, PhD, FACS
Associate Professor of Surgery
Yale School of Medicine
In 2014, a now 61-year-old male had a total thyroidectomy and central neck dissection for bilateral papillary thyroid cancer with extrathyroidal extension. Now, after presenting with recurrent metastatic papillary thyroid cancer, Dr. Tobias Carling performs a bilateral modified radical neck dissection.
Tobias Carling, MD, PhD, FACS
Associate Professor of Surgery
Yale School of Medicine
One of the early adaptors of the approach, Tobias Carling, MD, PhD, FACS, performs a right posterior retroperitoneoscopic adrenalectomy on a patient that presented with subclinical Cushing's syndrome. Specifically, she had elevated urinary cortisol, failed a dexamethasone suppression test, and had a growing adrenal tumor as revealed by serial imaging. Due to the patient’s anatomy, Dr. Carling used a lateral approach to ligating the right adrenal vein; this video includes his usual medial approach as an additional module.
A 60-year-old female’s biochemical workup concluded she had primary hyperparathyroidism, and preoperative images suggested a left lower parathyroid lesion. Consequently, Dr. Tobias Carling performed a minimally invasive parathyroidectomy under local cervical anesthesia while preserving the esophagus and recurrent laryngeal nerve. Intraoperative PTH proved complete resection.
