Primary hyperparathyroidism is usually caused by a single hyperfunctional parathyroid gland. Resection of this hyperfunctional gland usually can be performed by the transcervical approach; an approach also effective for glands located within the mediastinum. Rarely, some parathyroid glands are located deep within the mediastinum requiring a thoracic approach for excision. We present a video of a mediastinal parathyroid adenoma resected by thoracoscopy.

A 52 year old female presented with myalgia and fatigue. She denied other symptoms of hypercalcemia and there was no history to suggest a familial form of hyperparathyroidism. Her serum calcium was mildly elevated with an associated elevation in the intact PTH. The 24 hour urinary calcium and renal function studies were normal. Sestamibi scan and computer tomography (CT) scan localized the lesion to the anterior mediastinum, adjacent to the origins of the aorta and pulmonary artery. Left thoracoscopy was chosen over a cervical approach due to the depth of the lesion and the lack of thymic tissue available for traction as determined by CT scan. Thoracoscopic excision was performed without complication. Intraoperative rapid PTH assay showed a decline of greater than 50% of the preresection baseline, falling to normal range 5 minutes after resection. Pathology revealed an 8.2 g parathyroid adenoma.

Resection of a mediastinal parathyroid adenoma can effectively and safely be performed by thoracoscopy. We would not suggest a thoracoscopic approach for initial parathyroid exploration without preoperative localization. Intraoperative rapid PTH evaluation is helpful in confirming a curative resection, thereby avoiding cervical exploration.