Video Assisted Thoracoscopic Surgery: Benefits & Challenges

Ectopic mediastinal parathyroid adenomas (EMPA) are a rare but important cause of primary hyperparathyroidism (PHPT). These adenomas occur when parathyroid tissue grows in the wrong place, often in the mediastinum. Surgery is the only cure and the advent of minimally invasive techniques like Video-Assisted Thoracoscopic Surgery (VATS) has changed the game. This blog will explore the role of VATS in the excision of EMPA, as well as the indications, the procedure, and the benefits. 

What are Ectopic Mediastinal Parathyroid Adenomas

Parathyroid glands regulate calcium levels in the blood through parathyroid hormone (PTH). Hyperfunctioning parathyroid tissue like an adenoma can cause hypercalcemia and symptoms like kidney stones, bone pain, fatigue and neuropsychiatric disturbances.

Ectopic parathyroid adenomas account for 10-15% of PHPT cases. Of these, mediastinal adenomas are a small subset. These aberrant adenomas occur due to embryological migration errors and often settle in the anterior or posterior mediastinum. Given their location, surgical access to these adenomas can be tricky. Hence, minimally invasive approaches like VATS are a godsend. 

Indications for Surgery

Patients with ectopic mediastinal parathyroid adenomas usually present with:

• Persistent hypercalcemia despite medical treatment.
• Elevated serum PTH levels indicate autonomous parathyroid activity.
• Symptoms of hyperparathyroidism, skeletal or renal complications.
• Diagnostic imaging shows an ectopic adenoma in the mediastinum.

When medical treatment fails, or complications occur, surgery is indicated. 

The Role of Video-Assisted Thoracoscopic Surgery

VATS is a minimally invasive surgical technique done through small incisions with a thoracoscope with a camera and specialised instruments. This is now the standard for exercising ectopic mediastinal parathyroid adenomas because of its precision, low morbidity and good patient outcomes. 

Video-Assisted Thoracoscopic Surgery (VATS)

Preoperative Evaluation

• Localisation Studies: Preoperative imaging is important to identify the exact location of the ectopic adenoma. Techniques include:
• Sestamibi Scintigraphy: Highlights hyperfunctioning parathyroid tissue.
• CT or MRI: Provides anatomical information about the mediastinum.
• 4D CT Scanning: Combines functional and anatomical imaging for precise localisation.
• Patient Preparation: The patient is evaluated for cardiac and pulmonary status due to the thoracic approach.

Surgical Technique

• Anaesthesia and Positioning: Patient is placed under general anaesthesia in a lateral decubitus position to access the thorax.
• Incisions and Thoracoscope Insertion: Small (1-3 cm) incisions are made to insert the thoracoscope and instruments. The camera shows high-definition images of the mediastinal structures.
• Dissection and Excision: Surgeon identifies and isolates the ectopic adenoma, protects adjacent structures like oesophagus, trachea and major vessels. Intraoperative PTH monitoring may be done to confirm complete adenoma removal.

Postoperative Care

• The patient is monitored for complications like pneumothorax or recurrent laryngeal nerve injury.
• Calcium and PTH levels are closely monitored to check the success of the surgery and to manage transient hypocalcaemia if needed. 

VATS Benefits

VATS has several advantages over open thoracotomy:

• Minimally Invasive: Smaller incisions mean less pain, scarring and recovery time.
• Better Visualisation: High-def cameras give you a better view of the surgical site.
• Less Morbidity: Lower risk of infection, bleeding and post-op complications.
• Shorter Hospital Stay: Most patients go home in a few days.
• Faster Recovery: Patients get back to normal sooner than open surgery. 

Challenges and Considerations

Despite the benefits, VATS requires special training and equipment. Few challenges:

• Difficult Localisation: Even with imaging, finding small ectopic adenomas in the mediastinum can be challenging.
• Anatomical Complexity: The mediastinum has critical structures, so you must be careful during dissection.
• Conversion to Open Surgery: Rarely, VATS may need to be converted to open thoracotomy if the adenoma can’t be safely removed. 

Patient Outcomes

Studies have shown excellent outcomes for VATS in removing ectopic mediastinal parathyroid adenomas. The success rate for complete adenoma removal is high, and most patients get their calcium and PTH levels back to normal after surgery. VATS is minimally invasive, so patients are happier and recover faster than the traditional approach.>

Conclusion

Video-assisted thoracoscopic Surgery (VATS) is the new standard of care for ectopic mediastinal parathyroid adenomas. It's minimally invasive and precise, with faster recovery, and it’s the way to go for these rare but important conditions. Patients with suspected ectopic adenomas should see experienced VATS surgeons to get the best results. As technology and techniques advance, VATS will be the future of mediastinal parathyroid surgery.