EJSO 2003; 29: 188±190 doi:10.1053/ejso.2002.1313 EDUCATIONAL SECTION Minimally invasive video assisted parathyroidectomy (MIVAP) P. Miccoli, P. Berti, G. Materazzi and G. Donatini Department of Surgery, University of Pisa, Pisa, Italy The first endoscopic approach to parathyroid glands was reported by M. Gagner in 1996. Later, different accesses have been described using either CO 2 insufflation or external retraction. Other widespread procedures include the lateral access proposed by J.F. Henry and the central gas-less access proposed by P. Miccoli. We hereby describe this central access which allows a bilateral exploration of the neck when necessary. Our patient data base consists of 270 patients operated on since February 1997. The mean age was 56.5 years (20±87 years). The female to male ratio was 4 : 1. The mean operative time of the procedure was 41.1 min (range 15±180 min). In 13 cases, a video-associated thyroid resection was accomplished during the same operation for associated diseases. Conversion to traditional cervicotomy was required in 20 patients (8.09%). One laryngeal nerve palsy was confirmed 6 months after surgery. We registered one postoperative bleeding, which required us to reoperate on the patient 2 hours after first surgery. The mean operative time and complication rate clearly demonstrate that this approach, like other minimally invasive techniques, can successfully rival the results of traditional surgery for the treatment of primary hyperparathyroidism. # 2002 Elsevier Science Ltd. All rights reserved. Key words: hyperparathyroidism; video-assisted parathyroidectomy. INTRODUCTION The first endoscopic approach to the parathyroid glands was reported by Michel Gagner in 1996. 1 Access has been described using CO 2 insufflation, external retrac- tion, lateral access as proposed by J. F. Henry 2 and central gasless access as proposed by Miccoli. 3,4 We here describe the central access approach which allows bilateral exploration of the neck. TECHNIQUE The patient is placed in supine position, without hyper- extension of the neck, so as to increase the working space under the strap muscles. The skin is prepared to allow a possible conversion to the traditional cervicotomy. A 15 mm tranversal incision (Fig. 1) is performed 2 cm above the sternal notch, subcutaneous fat and platysma are carefully dissected. The cervical linea alba is divided longitudinally for up to 4 cm. The strap muscles on the side of the adenoma are then gently retracted with one small conventional retractor. A second retractor is placed directly on the thyroid lobe, which is retracted medially and lifted up. The dissection of the lobe from the strap muscles is performed under direct vision.  1.5 cm transversal skin incision 2 cm above the sternal notch.  dissection of the strap muscles from the thyroid lobe.  operative space maintained by means of small retractors.  introduction of endoscopic instruments (30  5 mm endoscope, small forceps and spatulas) and dissec- tion of the adenoma.  haemostasis achieved by means of vascular clips and/or electrocautery. 0748±7983/03/$30.00 # 2002 Elsevier Science Ltd. All rights reserved. Correspondence to: Paolo Miccoli, MD, Dipartimento di Chirurgia, Via Roma 67, 56100, Pisa, Italy. Tel:  39 050992400; Fax:  39 050551369; E-mail: p.miccoli@dc.med.unipi.it