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Mediastinotomy for Parathyroid Adenoma
Mediastinotomy for Parathyroid Adenoma HERBERT D. ADAMS, M.D.
THE COMBINED cervical mediastinal approach described in the preceding article should also be used at times in the surgical management of hyperparathyroidism caused by parathyroid adenoma. The prevention and cure of the serious complications of hyperparathyroidism resulting from parathyroid adenoma are primarily related to the accurate localization and removal of the adenoma. It is apparent, however, that many surgeons who attempt this operation have no preconceived idea of the successive steps, beyond exploration of the neck, that must be taken if these adenomas are to be removed successfully at the first operation in a high percentage of cases. This is evident by the number of cases in which lengthy operations are performed without finding the adenoma, and by the frequency of multiple operations. To accomplish this all-important localization of the adenoma, the following four consecutive operative steps should be carried out: (1) adequate exploration of the neck; (2) extraction through the neck incision of the fibroareolar and thymic tissue from behind the manubrium lying in the triangle formed by the innominate and left carotid arteries and veins where a high percentage of the adenomas located in the anterior mediastinum will be found. If the adenoma is not located by these two steps, (3) a sternal-splitting extension of the neck incision should be utilized, removing all the fibroareolar and thymic tissues from the anterior mediastinum. If the adenoma has not been found by these three consecutive maneuvers, (4) a total thyroidectomy, especially if an adenomatous goiter is present, should be performed since in a small percentage of cases an adenoma will be found within the substance of the thyroid gland. The excellent anatomical exposure of the entire anterior cervical region obtained by this approach and the ability to extend the incision to the superior mediastinum when indicated provide a perfect solution to the problem of localization and the uniformly successful removal of parathyroid adenoma or adenomas. These procedures should be undertaken, however, only if there is a prior clinical conviction that an adenoma is present. This depends upon
665
666
HERBERT
D.
ADAMS
the accumulation of strong confirmatory evidence based upon appropriate laboratory tests. Space will not permit here a discussion of the differential diagnosis and the selection of cases. When the diagn0sis of hyperparathyroidism has been established and surgery is advised, however, it has been our experience that a high percentage of adenomas can be found by the consecutive operative procedures described without adding to the risk to the patient or subjecting him to subsequent operations.
THE COMBINED cervical mediastinal approach described in the preceding article should also be used at times in the surgical management of hyperparathyroidism caused by parathyroid adenoma. The prevention and cure of the serious complications of hyperparathyroidism resulting from parathyroid adenoma are primarily related to the accurate localization and removal of the adenoma. It is apparent, however, that many surgeons who attempt this operation have no preconceived idea of the successive steps, beyond exploration of the neck, that must be taken if these adenomas are to be removed successfully at the first operation in a high percentage of cases. This is evident by the number of cases in which lengthy operations are performed without finding the adenoma, and by the frequency of multiple operations. To accomplish this all-important localization of the adenoma, the following four consecutive operative steps should be carried out: (1) adequate exploration of the neck; (2) extraction through the neck incision of the fibroareolar and thymic tissue from behind the manubrium lying in the triangle formed by the innominate and left carotid arteries and veins where a high percentage of the adenomas located in the anterior mediastinum will be found. If the adenoma is not located by these two steps, (3) a sternal-splitting extension of the neck incision should be utilized, removing all the fibroareolar and thymic tissues from the anterior mediastinum. If the adenoma has not been found by these three consecutive maneuvers, (4) a total thyroidectomy, especially if an adenomatous goiter is present, should be performed since in a small percentage of cases an adenoma will be found within the substance of the thyroid gland. The excellent anatomical exposure of the entire anterior cervical region obtained by this approach and the ability to extend the incision to the superior mediastinum when indicated provide a perfect solution to the problem of localization and the uniformly successful removal of parathyroid adenoma or adenomas. These procedures should be undertaken, however, only if there is a prior clinical conviction that an adenoma is present. This depends upon
665
666
HERBERT
D.
ADAMS
the accumulation of strong confirmatory evidence based upon appropriate laboratory tests. Space will not permit here a discussion of the differential diagnosis and the selection of cases. When the diagn0sis of hyperparathyroidism has been established and surgery is advised, however, it has been our experience that a high percentage of adenomas can be found by the consecutive operative procedures described without adding to the risk to the patient or subjecting him to subsequent operations.