Traditional management of mediastinal parathyroid adenomas has required mediastinal exploration via sternotomy or thoracotomy. Minimally invasive approaches via videoscopic transthoracic or transcervical approaches offer excellent visualization and decreased patient morbidity. The Rultract Skyhook system provides increased access to the superior and anterior mediastinum via a transcervical approach. Access to the middle and posterior mediastinum require a transthoracic approach which can be performed safely using Video-assisted thoracoscopic surgery (VATS). The preoperative localization, video-assisted transcervical and transthoracic techniques, intraoperative confirmation of the adenoma and complications are reviewed. Five consecutive patients had mediastinal exploration of which three were performed transcervically and three transthoracically, (one patient underwent both procedures). One patient had a negative thoracic exploration; another's course was complicated by recurrent laryngeal nerve injury which resolved with non-operative management. Transcervical approaches to resection of a mediastinal parathyroid adenoma are possible with the use of the Rultract Skyhook system. We believe that this retraction system provides access to the anterior and superior mediastinum, allowing for the use of video-assisted visualization that aids resection of the mediastinal parathyroid adenoma without sternotomy. VATS provides excellent visualization of the middle and posterior mediastinum avoiding the morbidity of thoracotomy.