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Minimally Invasive Parathyroidectomy

By Macquarie University Hospital | Published May 15, 2012

Primary hyperparathyroidism is a common endocrine disorder characterised by excessive secretion of parathyroid hormone from one or more parathyroid glands. As the parathyroid hormone regulates primarily the metabolism of calcium, it affects its absorption, excretion and deposits; namely in the digestive tract, the renal and the skeletal systems.

The causes of primary hyperparathyroidism have been traditionally documented as follows:

- Single Parathyroid Adenoma 84%
- Multiple Parathyroid Adenoma 1%
- Parathyroid Hyperplasia 14%
- Parathyroid carcinoma <1%

This is a benign disease, the prevalence of Parathyroid carcinoma is so low that is constitutes a rarity. Although there are medical therapies for management of hypercalcemia, primary hyperparathyroidism is best served by surgery. Minimally Invasive Parathyroidectomy (MIP) has gained adepts all over the world due to its safety, efficacy and outstanding cosmetic outcome.

The procedure relies heavily on preoperative localisation of the gland, fundamentally to rule out hyperplasia or multiple parathyroid adenomas that would force the surgeon into a bilateral exploration. We largely use a combination of Sestamibi scan and ultrasound. Lately we introduced the use of ultrasound in the operating theatres to more effectively localise the gland and minimise the rate of failures. In fact most failures of the procedure that would require a conversion into a conventional bilateral neck exploration are related mainly to inadequate preoperative localisation. These failures fortunately are becoming uncommon as preoperative localisation is becoming more precise.

Once the glands are localised the surgeon places a 2 cm incision and removes the affected gland using a lateral approach. This approach retracts the infrahyoid muscles medially allowing the excision of the gland through a minimal incision. The procedure is safe, effective and achieves a high degree of patient satisfaction.

The key to endocrine surgery is a surgeon who subspecialises in this particular field and has acquired the training and experience to safely perform these procedures with good results.

Dr Nicolás Oddone is a Surgical Oncologist and Head & Neck Surgeon who has a special interest in thyroid, parathyroid and salivary gland disorders as well as minimally invasive approaches. For more information on these procedures please contact us at Suite 302, 2 Technology Place, Macquarie University Hospital NSW 2109 or ring 02 9887 8899.

References:

1. D Fraker, H Harsono, R Lewis. Minimally Invasive Parathyroidectomy: Benefits and requirements of intraoperative localisation, diagnosis and intraoperative PTH Monitoring. Long Term Results. World J Surg (2009) 33:2256–2265.
2. O Hessman, J Westerdahl, N Al-Suliman et al. Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism. British Journal of Surgery 2010; 97: 177–184.
3. R Udelsman, P Donovan. Open minimally invasive parathyroid surgery. World J. Surg. 28, 1224–1226, 2004.

Dr Nicolás Oddone, Surgical Oncologist and Head & Neck Surgeon

Guest Bloggers – from time to time MUH invites our specialists to provide content on our MUH Blog. Please note that with all guest bloggers the views and opinions expressed in these articles are those of the individual and are not necessarily the views of Macquarie University Hospital.

Posted in Endocrine Disorder, Macquarie University Hospital, Thyroid

Gamma Knife

By Macquarie University Hospital | Published March 5, 2012

No doubt you will all have heard about the wonderful equipment here at Macquarie University Hospital. On that list is this strange thing called a Gamma Knife – “brain surgery without blood”. Well, a Gamma Knife is not a knife at all. It is a machine that houses multiple (192) radioactive sources that are arranged to focus the radiation dose down onto a point. We can then place the target lesion under this fixed point so we can treat it.

The Gamma Knife uses radiation to deliver this dose as a single treatment with sub-millimetre accuracy, and in the process the dose to the surrounding tissue (usually brain) receives a much smaller and (much) less damaging dose. The whole treatment process takes a day to go through, but the actual dose delivery varies from 15 minutes to several hours depending upon the complexity of the volume being treated.

The Gamma Knife is only suitable for lesions that are above the 2nd cervical vertebra, i.e. inside the head and upper neck. Mostly it is used for lesions that are inside the skull itself, i.e. intracranial masses. Being a single dose of radiation, it is only useful for lesions that respond to radiation, which includes cerebral arterio-venous malformations (AVMs), trigeminal neuralgia and different neoplasms – tumours within the brain. These tumours can be lesions that have arisen within the brain (primary neoplasms) or have arisen from other sites (metastatic lesions).

Primary brain lesions can be treated for residual disease in a post-operative setting (e.g. meningiomas that are too heavily wrapped around important vessels or pituitary adenomas too close to the optic apparatus). These lesions can also be treated in a radical setting instead of surgery. This can be very useful when lesions are too close to critical structures where surgery might cause unwanted side-effects. An example of this would be operating on acoustic neuromas where traditional surgery might worsen deafness or cause a facial palsy.

Metastases are when a cancer has spread into the brain. In this case the Gamma Knife can be used either in conjunction with or instead of whole brain radiotherapy (WBRT). Although these two processes both use radiation as a treatment tool they are very different. They can however significantly complement one another– the GK can be used first with WBRT in reserve, or vice-versa.

The number of metastases, their location, their size and the extent of disease elsewhere, are all important factors that must also be taken into consideration when deciding on whether the GK treatment is appropriate. At present the out-of-pocket expense for using this treatment is high because the GK uses significant imaging and staffing resources. We are in the process of obtaining a Medicare rebate for the GK, and as a consequence, patients are currently required to pay for GK treatments upfront.

We believe that this treatment should be considered by all the associated clinicians in a patients care schedule.

Our GK clinicians here at the hospital, firmly believe that communication with a patient’s extended medical team is essential in providing the best possible care and treatment, particularly since many patients come from outside our immediate catchment area, and as such need to have local resources for follow-up.

Michael Izard ADM, MBBS FRANZCR MMedicalHum, Clinical Senior Lecturer
Australian School of Advanced Medicine and Macquarie University Hospital

Posted in Gamma Knife, Macquarie University Hospital

Innovative Investigation Improves Safety and Reliability of Breast Reconstruction Surgery

By Macquarie University Hospital | Published February 14, 2012

Using the patient’s own tissue for reconstruction of the breast after mastectomy has long been considered a better option for most women than the use of implants. Lower abdominal skin and fat are ideal for this, as most women in the common age-groups for breast cancer have laxity of this area from pregnancies. They appreciate the “win-win” opportunity to have a “tummy tuck” at the same time as getting a new breast. Over the last decade, the deep inferior epigastric artery perforator flap (DIEP), which uses this lower abdominal tissue, has become the “platinum standard” for breast reconstruction after mastectomy. Unlike the previous “gold standard”, the TRAM flap, the DIEP flap takes no muscle out of the abdominal wall. Abdominal wall weakness and hernia risk are thus lessened. Relying for its blood supply on small “perforating” arteries that pass through the abdominal rectus muscle to supply the skin and fat, the reliability of this flap is now more predictable. This is due to an innovative application of a pre-operative investigation called spiral CT angiography (CTA). CTA allows not only visualization of these small vessels, but their position can be accurately mapped on the patient’s abdomen and even their internal diameters measured. This allows the surgeon to choose the best blood vessels before the surgery, and takes away uncertainty about where the vessels are located and how large they may be.

Furthermore, measurement of the diameter of the perforators allows a mathematical formula to be applied that can predict how many of these blood vessels are needed for a given breast-flap size and permits the surgeon to accurately plan the procedure well before the actual operation. The risk that small parts of the flap may undergo necrosis (requiring further surgery) is thus much lessened, and the whole exercise is beneficial to both patient and surgeon. The procedure has a very high patient approval rate. Our team at Macquarie is pioneering the use of these techniques in breast reconstruction, and patients are benefitting from more reliable surgery. More information may be found on Prof Pennington’s website at www.davidpennington.com.au

Associate Professor David Pennington, FRCS(Ed),FRACS

Guest Bloggers - from time to time MUH invites our specialists to provide content on our MUH Blog. Please note that with all guest bloggers the views and opinions expressed in these articles are those of the individual and are not necessarily the views of Macquarie University Hospital.

Posted in Breast Reconstruction Surgery, Macquarie University Hospital

Urology: Getting smarter with robotic technology

By Macquarie University Hospital | Published November 3, 2011

Macquarie University Hospital has recently invested in the da Vinci surgical system, an advanced robotic surgical tool to boost the hospital’s oncology, urology and gynaecological capabilities. Our doctors will initially use this system for urological cases, with a focus on prostate surgery. However the technology will eventually be utilised by a number of specialities.

Around 20,000 new cases of prostate cancer are diagnosed in Australia every year and one in five Australian men will develop prostate cancer by age 85. It is the most common form of cancer and the second most common cause of cancer deaths in Australian males.

We’re very excited about this new technology to equip our talented surgical team.

The new da Vinci surgical system is a minimally invasive technique.

The acquisition makes Macquarie University Hospital one of only two hospitals in Sydney to offer this unique and intuitive technology.
Urology is one of Macquarie University Hospital’s core areas of treatment. The da Vinci Surgical System is a robotic technology that facilitates complex laparoscopic procedures.

The da Vinci system provides surgeons with all the clinical and technical capabilities of traditional surgery while enabling them to operate through a few tiny incisions, smaller than a centimetre. Delicate tissue can be handled and dissected even in the most confined spaces such as the chest, abdomen and pelvis.

The da Vinci has an ergonomically designed console positioned alongside the patient, where the surgeon sits while operating. Surgeons have an immersive view of the surgical field with extremely high-definition 3D vision, allowing for precision and control. Four interactive robotic arms, which are precisely calibrated, are positioned above the patient.

This technology also allows each individual surgeon’s hand movements to be scaled, filtered and translated into precise movements of the instruments that are working inside the patient’s body.

The latest da Vinci Robot also has a greater range of hand movement and visual acuity than a human hand. The high-definition 3D image provides the surgeon with unprecedented vision that enables surgical precision around vital structures. This becomes important when performing nerve sparing prostate cancer surgery.

The benefits to patients are immense. It has been well documented that patients experience a faster recovery with a reduced stay in hospital. There is significantly less post-operative pain and a lower risk of infection. Longer term results see reduced scarring and fewer post-operative complications.

The Macquarie University Hospital system will be used across several areas of urological surgery. While prostate cancer will be the most common condition to be addressed, the da Vinci system will also be used to treat bladder and kidney cancer.

The acquisition of the da Vinci system further enhances Macquarie University Hospital’s reputation as a major centre for minimally invasive urological surgery – with one of the key treatments of urological services being cancer. Cancer services is one of the hospital’s core areas of clinical emphasis.
For further details click here

Carol Bryant
CEO
Macquarie University Hospital
Phone 9812 3011

Posted in da Vinci surgical system, Urology

Latest news from one of Sydney’s newest hospitals: Macquarie University Hospital

By Macquarie University Hospital | Published June 14, 2011

I am delighted to take on the new challenge of leading the team at Macquarie University Hospital.
It is an exceptional facility, with extraordinary technology. The hospital’s most important asset however, is its people. Although I have not had the opportunity to meet all the staff as yet, it is evident from what has been achieved in the first year of operation, that the team assembled is committed to and passionate about this organisation.
Having worked in executive positions within the private hospital sector for the past 22 years, the last eleven of which have been as CEO at Westmead Private, I am acutely aware of the obstacles faced by new entrance into this sector. Building loyalty amongst the community and doctors is challenging, but we are well on our way to achieving this together.
Next week we celebrate the hospital’s first year anniversary. Every single employee plays a valuable role in the running and growth of this facility. The hospital’s executive recognises the enormous contribution our staff have made thus far and want to continue to provide the support and encouragement necessary to ensure our organisation develops from strength to strength.
It is exciting to be part of developing a new model of private health care in Australia. Rather than simply looking at best practice in Australia, our focus on new technology and innovative systems demonstrates our desire to benchmark internationally.
As the first private facility on a university campus – based on university hospitals in the United States, our links with research and education, and our integrated and collaborative approach amongst staff, doctors, departments and our partner organisations, enables us to offer a unique service with the aim of providing superior clinical outcomes and the best available care. Breaking new ground always comes with its challenges but together we will continue to achieve great things.

Posted in Macquarie University Hospital