Transaxillary Approach for a Retrosternal Parathyroid Adenoma

Despoina Daskalaki, MD, Krisitn Patton, MD, Fabiola Aguilera, MD, Mario Masrur, M Rashdan, F Bianco, Pc Giulianotti, MD, FACS. University of Illinois Hospital and Health Sciences System

Background: We present the case of a 46-year-old female that was referred to us for primary hyperparathyroidism. Pre-operative imaging with SPECT CT and chest CT scan confirmed the presence of a 12 mm left, inferior retrosternal nodule. The patient was evaluated for robotic transaxillary versus transthoracic left parathyroidectomy. We opted for the transaxillary approach.  

Results: Intraoperatively, the patient was positioned supine with the left arm partially abducted to expose the axilla. A 6 cm incision was made in front of the lateral tendon of the pectoralis muscle. The working space was created dissecting in front of the fascia, reaching the clavicle and entering into the neck space. Dissection continued between the two heads of the sternocleidomastoid muscle, reaching the strap muscles and prethyroid muscles. A self-maintaining retractor was then placed and the robotic system was docked, coming from the patient’s right side. The lower pole of the thyroid was explored and the large adenoma was identified partially going behind the sternum. The nodule was then removed using the Harmonic device. The intraoperative parathormone levels dropped from 364 to 22 pg/ml after removal of the enlarged parathyroid. Frozen pathology confirmed the presence of hyperplastic tissue. The operative time was 90 minutes, including docking time. The postoperative course was uneventful and the patient was discharged on POD 2.

Conclusions: The intrinsic technical advantages of the robotic system allow precision of movement even in narrow surgical environments. Robotic transaxillary parathyroidectomy is an interesting technique that allows dissection in the upper mediastinum. It is a valid minimally invasive approach, even in more complex lesions, such as large, retrosternal adenomas. 

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