Mediastinal Parathyroidectomy by Video-Assisted Thoracoscopic Surgery for Persistent, Sporadic, Primary Hyperparathyroidism in an Adolescent

Introduction: Treatment for primary hyperparathyroidism in the appropriately selected symptomatic or asymptomatic patient includes surgical removal of the hypercellular parathyroid gland(s). Up to 20% of abnormal parathyroid glands causing primary or secondary hyperparathyroidism are located ectopically. Depending on location, mediastinal parathyroid adenomas may be successfully extirpated via a traditional cervical surgical approach. However, if unable to access via this approach, alternative methods originally included sternotomy or thoracotomy. The recent rise in minimally invasive techniques have been shown to reduce morbidity and improve postoperative recovery. We demonstrate a mediastinal parathyroidectomy via video-assisted thoracoscopic surgery (VATS) approach while utilizing intraoperative parathyroid hormone guidance and frozen-section pathologic analysis. Materials and Methods: The patient is a 13-year-old female with a biochemical diagnosis of primary hyperparathyroidism and a past history significant for nephrolithiasis. Four months prior, the patient underwent a cervical exploration with the removal of two left-sided parathyroid glands and a right cervical thymic remnant with parathyroid tissue; however, this failed to resolve her parathyroid disease. Chest computed tomography and a nuclear medicine parathyroid scan did demonstrate a paraaortic, thymic nodule consistent with parathyroid tissue. A right VATS thymectomy was recommended. Results: After accessing the right chest by VATS approach, the thymus was identified and dissected free from the pericardium, phrenic nerve, superior vena cava, and aortic arch. Intraoperative parathyroid hormone guidance confirmed an appropriate reduction after thymectomy was complete. She was discharged from hospital on postoperative day two with calcium supplementation and Calcitriol. Conclusions: Ectopic mediastinal parathyroid adenomas are an uncommon cause of primary hyperparathyroidism. VATS thymectomy provides a safe and effective approach for resection. No competing financial interests exist. Runtime of video: 4 mins 15 secs Acknowledgment: The source of the study is the Division of Pediatric Surgery at Penn State Milton S. Hershey Medical Center. Patient Consent: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.