Heterotopic parathyroid autotransplantation in total parathyroidectomy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anterior triangle of the neck

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    Situated between the anterior margin of the sternocleidomastoid muscle, the mandibula and the jugular fossa, the anterior cervical triangle near the hyoid bone comprises the suprahyoid and subhyoid muscles, vessels, nerves and the thyroid. The only important subhyoid muscles in thyroid surgery are the medial

    • sternohyoid muscle (sternum → hyoid bone) which covers the
    • sternothyroid muscle (sternum → thyroid cartilage of the larynx) and more laterally the
    • omohyoid muscle (scapula → intermediate tendon→ hyoid bone)

    because they partly cover the thyroid gland and must be retracted laterally.

    Blood vessels

    Before dividing into the internal and external carotid artery, its two main branches, at the superior margin of the thyroid cartilage at the level of its carotid sinus (pressoreceptors for the blood pressure and chemoreceptors for the blood gases), the carotid artery courses in the carotid sheath immediately lateral to the trachea and esophagus. Here, it touches the left and right thyroid lobe as a major blood vessel. The internal jugular vein arises from the sigmoid sinus in the skull, collects the blood from the head and neck, and while coursing caudad it first accompanies the internal carotid artery in the carotid sheath before pursuing a more lateral course, enclosing the lateral aspects of the common carotid artery and vagus nerve (CN X).

    Nerves

    The ansa cervicalis (superior and inferior roots, from C1-C3), which innervates these three above muscles of the anterior triangle of the neck, and the transverse nerve of the neck (from C2/3, innervation of skin and platysma) courses cephalocaudad lateral to the thyroid and next to the vagus nerve and its superior branch to the larynx (superior laryngeal nerve → anterior cricothyroid muscle and mucosa of the superior laryngeal half).

    Fascial layers

    The skin of the anterior triangle of the neck covers several fascial layers (all belonging to the cervical fascia) with distinctive features:

    • The superficial lamina invests all structures of the neck, except for the platysma, and separately invests the sternocleidomastoid muscle as well as the posterior aspect of the trapezius muscle (accessory nerve XI),
    • with the medial pretracheal lamina investing the infrahyoid muscles and
    • the deep prevertebral lamina coursing outside the surgical field between the esophagus and spine.

    Just like the lateral vascular and nerve pedicle (carotid artery, internal jugular vein and vagus nerve), the trachea and thyroid / parathyroids also have their own organ fascias. With their three-dimensional configuration, the fascias invest compartments interspersed with spaces which extend into the mediastinum and thus represent potential routes of infection.

  • Thyroid region

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    The unpaired thyroid (glandula thyroidea) and the 4 parathyroids (glandula parathyroidea) are part of the endocrine organ system. The thyroid gland is located in the anterior neck lateral and inferior to the thyroid cartilage, and comprises a left and right lobe and the isthmus which bridges both lobes. The lobes cover the lateral superior rings of the trachea as well as the anterior aspect of both the cricoid and thyroid cartilage; the isthmus sits in the midline at the level of the second and third tracheal ring. The organ is invested by its own capsule of connective tissue (capsula fibrosa) and covered anterolaterally by the infrahyoid muscles (sternohyoid, sternothyroid and omohyoid) and the pretracheal lamina. Due to its embryology and descent (via the thyroglossal duct) from the base of the tongue (foramen caecum) to its later location, its path may leave cysts or ducts to the foramen caecum, as well functional glandular tissue (e.g., pyramidal lobe).

    Blood supply

    Arteries from the external carotid (→ superior thyroid artery) and the subclavian artery via the thyrocervical trunk (→ inferior thyroid artery) with their small anterior and lateral/posterior branches supply the thyroid gland with blood. The thyroidea ima artery, an inconsistent but noteworthy artery arising directly from the aortic arch or the brachiocephalic trunk terminates in the thyroid from below. Venous drainage from this endocrine organ is via corresponding veins (superior and medial thyroid vein → internal jugular vein, inferior thyroid vein → brachiocephalic vein) and has systemic significance.

    Lymphatics and nerves

    Lymphatic drainage from the thyroid is paratracheal and to the deep cervical lymph nodes. Particular attention must be paid to the recurrent laryngeal nerve (from the vagus nerve (CN X), on right: looping around the subclavian artery; on left: looping around the aortic arch). It travels cephalad in the groove between trachea and esophagus to the larynx, where it supplies the sensory mucosal innervation of the inferior half of the larynx and all laryngeal muscles except the anterior cricothyroid (“anticus”).

    The four parathyroids (glandula parathyroidea), small oval glands on the posterior aspect of the thyroid lobes, are supplied by the inferior thyroid arteries.

  • Topography

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    Due to their proximity, thyroid surgery runs the risk of injuring not only structures such as the recurrent laryngeal nerve and the parathyroids on the posterior aspect of the organ, but also parts of the sympathetic trunk or vessels and nerves adjacent to the common carotid artery.

  • Anatomy and function of the parathyroids

    While the barely lentil-sized, paired parathyroids are usually found on the posterior aspect between the fibrous and external capsule of each lobe, sometimes they are located within the thyroid tissue itself.

    Most often, the superior parathyroids are at the level of the inferior margin of the cricoid cartilage, superior to the crossing of the inferior thyroid artery with the recurrent nerve, but posterior to the latter.

    The most common location of the inferior parathyroids is at the level of the third and fourth tracheal ring or inferior to the crossing of the inferior thyroid artery with the recurrent nerve, but anterior to the latter.

    The number and location of the parathyroids vary greatly, and in 95% of cases there are at least 4 parathyroid glands. Due to the long embryological migration of these glands, quite often their locations may vary and are atypical. They have been found in the connective tissue of the neck superior or inferior to the thyroid gland. Cephalad migration up to the angle of the jaw (carotid bifurcation) and particularly caudad into the thyrocervical ligament or even migration with the thymus into the anterior mediastinum has been described. Locations within the thyroid are mostly in the inferior third of the thyroid lobes.

    More than 80% of the parathyroid tissue is supplied by the inferior thyroid artery. The blood supply for the remainder comes from the superior thyroid artery and branches arising from the anastomoses between both thyroid arteries.

    The main function of the parathyroids is the formation and secretion of parathyroid hormone (PTH), a polypeptide comprising 76 amino acids.

    PTH controls the calcium metabolism by up-regulating renal re-absorption in the distal tubule. PTH release is primarily controlled by the serum calcium level. Renal hydroxylation of 25-cholecalciferol into1,25-dihydroxycholecalciferol, the active metabolite of vitamin D3, is controlled by PTH and regulates the intestinal absorption of calcium and phosphate.

    Most of the serum calcium binds to albumin (80%), but only the free, i.e., ionized, calcium exhibits physiological significance. The calcium-albumin binding depends on the pH and is strengthened by alkalosis.

    Since it controls the calcium metabolism, PTH impacts directly on the serum level of phosphate and magnesium.

  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 10.07.2012
  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Kocher or collar incision

    110-6

    Standard skin incision 2 finger widths (2-3 cm) superior to the suprasternal notch between the bellies of the left and right sternocleidomastoid muscles.

    With the Ligasure® divide subcutaneous tissue and platysma down to anterior fascia of the neck.

    Expose the avascular plane between platysma and anterior cervical fascia of and free the skin-platysma flap cephalad and caudad.

  • Midline division of the strap muscles

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    Divide the fascia and strap muscles in the midline while sparing the superficial veins of the neck. Then retract the strap muscles of the neck from the anterior aspect of the thyroid.

  • Freeing the right superior pole of the thyroid

    110-8

    Turn to the right thyroid lobe. Dissect the right side and successively free the superior pole. Expose the vessels of the superior pole and transect them close to the lobe between clips and Ligasure® seals.

  • Exposing the vagus nerve

    110-9

    Carefully free the right thyroid lobe while transecting the medial thyroid vein (Kocher vein).

    Locate and underrun the vagus nerve with a vessel loop. Neuromonitoring with the Medtronic system demonstrates normal signals.

  • Resection of the superior right parathyroid

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    Locate the recurrent laryngeal nerve and verify it by neuromonitoring. Then expose the superior right parathyroid at its typical location posterior to the recurrent laryngeal nerve.

    After sealing with the Ligasure® resect the parathyroid between clips.

  • Exploring the inferior parathyroid at its usual location

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    After resection of the enlarged nodular right thyroid lobe (not illustrated), once more locate and neuromonitor the recurrent laryngeal nerve, visible in its entire course,

    Then dissect at the usual location of the inferior parathyroid anterior to the nerve and inferior the inferior thyroid artery.

    Since the parathyroid cannot be located here, continue the dissection along the thyrothymic ligament to the right lobe of the thymus.

  • Starting the right transcervical thymectomy

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    Step by step and under gentle traction free the thymus cephalad outside its delicate capsule. Finally, within the right thymic lobe a markedly enlarged parathyroid is seen which can be resected after placing an inferior clip.

  • Thymectomy

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    Precise anterior dissection between clips and Ligasure® seals avoids bleeding and spares the recurrent laryngeal nerve.

    And finally, the left lobe of the thymic is also resected and extracted cephalad after deep ligature directly adjacent to the brachiocephalic trunk. The third parathyroid gland is now seen within the left lobe of the thymus.

  • Freeing the left thyroid lobe

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    Transect the right Kocher vein and free the left thyroid lobe laterally. Pull the lobe in an anteromedial direction with atraumatic Babcock forceps. Locate the vagus nerve within the carotid sheath and underrun it with a vessel loop. Verify correct functioning of the recurrent laryngeal nerve by neuromonitoring. After opening the space between the posterolateral aspect of the thyroid and the carotid sheath, filled with delicate alveolate connective tissue, expose the inferior thyroid artery. The recurrent laryngeal nerve crosses here and can be verified by neuromonitoring. After clip placement transect the left thyrothymic ligament and remove the entire thymus.

  • Resection of the superior left parathyroid

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    The left superior parathyroid gland manifests in its characteristic location superior to the inferior thyroid artery and is resected after sealing the delicate vessels with the Ligasure® forceps.

  • Final neuromonitoring

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  • Drain insertion

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  • Layered wound closure

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  • Preparing the graft

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  • Autotransplantation

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  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Ingolstadt

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