Surgery in primary hyperparathyroidism: the patient without previous neck surgery.

The indications for surgical exploration in the "asymptomatic" patient with primary hyperparathyroidism (1 degrees HPTH) have changed since the 1990 National Institutes of Health Consensus Development Conference. This seems to be, at least in part, caused by the introduction of minimally invasive parathyroidectomy (MIP) techniques. The concept of MIP is based on the fact that the majority of patients (80-85%) with 1 degrees HPTH have a single adenoma that can usually be identified on preoperative imaging. The incident adenoma can be resected under local or regional anesthesia, and an intraoperative adjunct, such as the rapid parathyroid hormone (PTH) assay, can be used to show an adequate decrement in plasma PTH levels. There are no randomized prospective trials comparing the results obtained with conventional and MIP techniques. However, a recent series of 656 consecutive parathyroid explorations compared the results obtained using conventional (n = 401) and MIP (n = 255) surgery. The success rate for the entire series was 98%, and there were no significant differences in cure rates between traditional (97%) and MIP (99%) techniques. The overall complication rates were also similar. However, MIP was associated with a 50% reduction in operating time, a 7-fold reduction in length of hospital stay, and a mean cost savings of $2693 per case. It seems likely that the majority of patients with 1 degrees HPTH can now be cured on an outpatient basis with MIP, which has already replaced conventional parathyroid exploration in several endocrine centers. Limitations to this procedure include the need for sophisticated adjuncts and a surgeon highly experienced in this new technique.