Uniportal subxiphoid approach for resection of an intra-thymic parathyroid adenoma: a case report

Massimo Castiglioni, Wolfram Karenovics, Frédéric Triponez, Benoît Bédat

Abstract

Ectopic parathyroid glands are frequently encountered. When patients develop hyperparathyroidism, a parathyroidectomy may be indicated. Normally, this is feasible through a cervical incision; however, a few patients may require a trans-sternal or trans-thoracic approach due to deeply located adenomas. Most surgeons currently use a thoracoscopic approach; however, this can cause postoperative neuropathic pain because of the trauma to the intercostal nerves. In the Video, we describe a uniportal subxiphoid approach for resection of an intra-thymic parathyroid adenoma causing hyperparathyroidism. We report the case of a 44-year-old woman who was referred for primary hyperparathyroidism. She had recurrent renal lithiasis, gastritis, fatigue and loss of concentration. Corrected serum calcium level was 2.9 mmol/L and parathormone 25 pmol/L. A scintigraphy scan localized an ectopic adenoma in the anterior mediastinum, below the left innominate vein. Under general anesthesia, a subxiphoid transverse incision was made and the retrosternal space was entered. A GelPOINT® Mini advanced access platform was placed and all the thoracoscopic instrumentations were inserted through this single port. Carbon dioxide was insufflated. During dissection, the ectopic adenoma was localized inside the thymus gland. This was confirmed by intra- operative angiography with Indocyanine green and a subtotal thymectomy was then performed. Intra- operative parathormone levels confirmed biological cure of primary hyperparathyroidism. The patient was discharged with normal serum calcium level and parathormone, without any pain medication. Uniportal subxiphoid technique might be considered as valid alternative to the standard thoracoscopic resection, possibly resulting in more favorable outcomes.