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It has been recently demonstrated that resection of the adrenal glands can be performed laparoscopically, providing certain advantages over conventional open surgery. The aim of this work was to determine the role of laparoscopy in the surgical approach to the adrenal glands. From June 1994 to December 1995, transperitoneal laparoscopic procedures were proposed in patients with a unilateral 8 cm or less non-malignant tumors of the adrenal gland. For tumors under 4 cm in diameter, only secreting tumors were removed. One patient had Cushing's disease and underwent bilateral resection. Among 58 patients requiring ablation of the adrenal gland; 37 (64%) underwent a laparoscopic procedure: 20 Conn adenomas, 8 Cushing adenomas, 1 Cushing's disease, 5 pheochromocytomas, 3 incidentalomas. Mean tumor size was 26 mm (7-75 mm). Two tumors were found to be malignant: one cortisone-secreting tumor and one leiomyosarcoma. Conversion was required in 4 cases (11%) due to difficulties in exposing the dissection in 3 cases and due to malignancy in 1. Mean operative time for unilateral operations was 159 minutes (75-300 minutes). There were no deaths. Morbidity included one hemorrhage via the trocar orifice requiring reoperation, one infarction of the spleen which regressed spontaneously, one parietal hematoma, and one case of phlebitis of the lower limb. The endocrinopathy was successfully cured in all patients with secreting tumors. The 21 other patients underwent open surgery. Laparoscopic access was contraindicated due to suspected malignancy in 10 cases, past surgical history in 7 and bilateral or extra-adrenal lesions in 4. Laparoscopic resection of the adrenal glands is the preferred technique in patients with Conn adenomas, Cushing adenomas and in most cases of pheochromocytoma. It is not indicated for malignant and/or very large tumor (> 8 cm). In our experience, the laparoscopic approach has replaced open posterior approach which is now only used exceptionally. Currently two-thirds of our patients with an indication for resection of the adrenal glands are operated laparoscopically.

Peroperative assay of intact parathormone has been proposed to improve the surgical results, either by confirming cure peroperatively or to indicate the need for further search in case of persistent pathological secretion. Between October 1992 and July 1994 parathormone was assay peroperatively during 136 operations for primary hyperparathyroidism in 135 patients. Seven samples were made for each patient in the operating theatre: at intubation, at skin incision (ti), at ablation of the pathological gland, then 15 (t15), 30 (t30) and 60 (t60) minutes later. All samples were assayed with the rapid technique and controlled the next day with the standard method. The correlation coefficient between the two methods was 0.97. Comparing the drop in intact parathormone levels between cured patients and those with persistent hyperparathyroidism after surgery showed statistically significant differences. We retained a dramatic drop in hormone level by 80% between t1 and t15 with persistent low levels between t15 and t30 (ratio t30 over t15 < 1) as the criteria of cure: the drop off between t1 and t15 is not sufficient to confirm cure. Peroperative assay of intact parathormone can be used to demonstrate the presence of remaining pathological parathyroid tissue, especially important in case of highly ectopic localizations. This assay technique is not particularly well adapted to routine parathyroid surgery for primary hyperthyroidism but has been reserved for cases planned for limited dissection (operations conducted under local anaesthesia and reoperations).

Nineteen cases of non-recurrent inferior laryngeal nerve were identified during 3791 cervicotomies for thyroid or parathyroid excision over the last 7 years, the nervous anomaly being of vascular anomaly origin in all cases. Predisposing factors for its onset during aortic arch development are discussed, together with possible symptomatology and means for preoperative diagnosis. Frequency in the cases reported was 0,54% from 3098 dissections on the right and 0,07% from 2846 dissections on the left. Although rare on the right and exceptional on the left, an aberrant non-recurrent pathway for the inferior laryngeal nerve represents a major, surgical risk during thyroid or parathyroid excision.

Operation for tumors responsible for a Conn's syndrome was performed in 16 patients, 11 women and 5 men, over a period of 13 years, the average time before diagnosis being 5 1/2 years. All patients presented hypertension, permanent in 14 and paroxysmal in 2 cases while blood potassium levels were below 3 mmol/l in all patients. Diagnosis was confirmed by elevation of plasma aldosterone and of urine tetrahydroaldosterone, associated with low plasma renin activity not responding to a stimulus. The tumor was demonstrated by imaging in 15 cases before operation and its mean size was 1.7 cm. Investigatory methods for diagnosis and localization are discussed. One patient died during the immediate post-operative period from decompensated cardiac failure. Long-term review showed persistent hypertension in 5 patients but electrolyte disturbances were corrected in all cases. Lack of consistency of results of surgical reduction in case of hyperplasia suggests that only patients with hyperaldosteronism related to an adrenal cortex tumor should be operated upon.

Results are reported of surgical treatment of hyperparathyroidism secondary to chronic renal failure in 231 patients who had undergone 250 operations over 16 years: 152 total parathyroidectomies associated in 151 cases with an autotransplant, 58 subtotal parathyroidectomies, 9 incomplete parathyroidectomies, I white cervicotomy and 39 repeat operations for persistent or recurrent hyperparathyroidism. Results were evaluated clinically, biologically and radiologically after a mean follow up of 4 years, and were rated good in 71.4% of cases. The quality of the results was independent of the type of parathyroidectomy practised: 71% good results after total parathyroidectomy with autotransplantation and 69% after subtotal parathyroidectomy. No significant difference was demonstrated between the two techniques with respect to mortality, postoperative morbidity and late complications. The only divergence seen was in relation to recurrences: recovery surgery at the cervical level after subtotal parathyroidectomy leaving a clearly identified glandular stump associated with a better result than repeat operation on grafts at brachial level after total parathyroidectomy and autograft. These results led to the adoption of a surgical routine for hyperparathyroidism secondary to chronic renal failure using subtotal parathyroidectomy combined with bilateral thymectomy. The operation of total parathyroidectomy without immediate autotransplant is reserved for cervical recovery surgical procedures. Whatever the technique used, frozen storage of removed tissue is the indispensable complement of parathyroidectomy.

Results are reported of four and a half years of experience with autotransplantation and cryopreservation of parathyroid tissue in thyro-parathyroid surgery. One hundred patients with hyperparathyroidism secondary to renal insufficiency were treated by total parathyroidectomy and partial autotransplantation, immediate in 98 cases and secondarily using their frozen stored tissue in the other two cases. Results were compared with those in 13 other patients treated during the same period by subtotal parathyroidectomy. Seven of 46 patients with primary parathyroid hyperplasia underwent total parathyroidectomy with immediate partial autotransplantation. Grafts were not used in the other two previously cervicotomized patients. All parathyroid tissue removed during these operations was frozen and stored if not used for grafting. Of 116 patients treated by enlarged total thyroidectomy for cancer, 34 received parathyroid autotransplants; complementary in 19 cases and substitutive in 15. Technique and results are described, and respective indications for autotransplantation and parathyroid cryopreservation discussed with respect to primary, secondary, persisting or recurrent hyperparathyroidism, and to total thyroidectomy for cancer.