Injury to the recurrent laryngeal nerve (RLN) remains a significant morbidity during thyroid and parathyroid surgery. The aim of this study is to elucidate normative RLN electromyographic (EMG) parameters.

This is a retrospective cohort study of patients who underwent Intraoperative neuromonitoring during thyroid and parathyroid surgery from February 2014 to March 2015. The inomed C2 NerveMonitor was used. We recorded the stimulation current, amplitude, and latency of the RLN before and after nerve dissection. We also observed the number of patients who had hoarse voice after surgery.

A total of 46 patients (14 male, 32 female) averaging 51 years old in age (20-77 years) were analyzed. The most commonly performed surgical procedure was total thyroidectomy (53.2%).

The median stimulation current for both the right and left RLN was 0.500 mA. The median amplitude for the left RLN was 1.060 mV and greater than that for the right RLN (0.930 mV) (p = 0.30). The median latency for the right RLN and left RLN was 2.40 ms with no difference between the sides. (p = 0.58).

Post dissection, the right RLN amplitude remained identical whereasthe left RLN amplitude decreased. Latencies of both RLNs decreased although the difference was not significant. Nature of pathology and site of surgery did not influence RLN latency and amplitude. No patients had hoarse voice.

This study highlights the normative EMG parameters for bilateral RLN nerve stimulation in an Asian population. No significant difference was noted in both pre- and postdissection RLN EMG parameters.

Soh G, Lee JWK, Boon OH, Boon TW, Parameswaran R, Yuan NK. Experience of Intraoperative Recurrent Laryngeal Nerve monitoring in a Single Centernormative Recurrent Laryngeal Nerve Electromyographic Data. World J Endoc Surg 2017;9(1):1-6.

Focused parathyroidectomy for primary hyperparathyroidism (pHPT) in patients with a single positive localizing scan may have an unacceptably high recurrence rate unless intraoperative parathyroid hormone (ioPTH) is used. The CaPTHUS score was previously developed to predict singlegland disease in such instances. We evaluated the accuracy of this model in a cohort of patients with pHPT in the UK.

CaPTHUS scores were calculated from prospectively collected data on consecutive patients undergoing surgery for pHPT [(1 point each for: Preoperative calcium ≥3 mmol/L; PTH ≥2 times upper limit; ultrasound (1 point) and sestamibi (1 point) positive for single enlarged gland; concordant positive scans]. Diagnosis of single or multigland disease was confirmed on pathology.

From June 2007 to October 2011, 324 patients (251 female, median age 66, 10.89) underwent surgery for pHPT guided with ioPTH. Single-gland pathology was observed in 291 (89.8%) patients and multi-gland disease seen in 33 (10.2%). In single-gland disease patients, significantly higher preoperative calcium (p = 0.030) and PTH levels (p = 0.033) were seen with sensitivities of 65.6% for ultrasound and 66.0% for sestamibi scanning. A CaPTHUS score ≥3 was seen in 51.2% of all patients with a positive predictive value (PPV) for single-gland disease of 99.4%.

A CaPTHUS score ≥3 was accurate at predicting single-gland disease in >50% of patients with pHPT, providing a similar PPV and reducing the need for ioPTH implementation in this population. However, recent conflicting literature suggests the CaPTHUS score may not be universally applicable, local audit is recommended before implementation.

James TW, Stechman MJ, Scott- Coombes DM. The CaPTHUS Scoring Model revisited: Applicability from a UK Cohort with Primary Hyperparathyroidism. World J Endoc Surg 2017;9(1):7-12.

The aim of this case report is to highlight an exceptional presentation of primary hyperparathyroidism.

Asymptomatic maternal hyperparathyroidism manifesting in the neonate as hypocalcemic convulsions is exceedingly rare.

Case report: Primary hyperparathyroidism has got a varied presentations. We present a case report of neonatal hypocalcemic convulsions secondary to asymptomatic maternal hyperparathyroidism. Here, the challenge in diagnosing this condition and management will be discussed in the context of available literature.

In the event of nonfebrile seizures in the neonate due to hypocalcemia, the mother has to be evaluated for primary hyperparathyroidism.

Clinical significance: Physicians’ awareness of this unique manifestation of primary hyperparathyroidism is essential for the appropriate management of both the mother and the neonate.

Timely identification and treatment of this condition will prevent complications in both.

Teja VS, Ramakrishnan R. Unusual Presentation of Primary Hyperparathyroidism: A Rare Case Report. World J Endoc Surg 2017;9(1):13-15.

We describe the rare case of a woman with adrenal intravascular papillary endothelial hyperplasia (IPEH) or Masson's tumor. We present relevant background information on IPEH and our case report, as well as describe a workup and treatment plan for the lesion.

Intravascular papillary endothelial hyperplasia (IPEH) or Masson's tumor is a rare lesion, i.e., predominantly found in the oral cavity, head, and neck.^1-4 To our knowledge, only six adrenal IPEH cases have been reported in the literature to date.⁴

A 49-year-old woman originally presented to us with an incidentaloma found on computed tomography scan. Due to the eventual size increase of the mass, a laparoscopic left adrenalectomy was performed. Pathologic evaluation of the mass revealed a 3 cm IPEH arising in a hemangioma within the adrenal gland.

Before the diagnosis of IPEH is considered as the etiology for an adrenal incidentaloma, it is crucial to rule out more common tumors. Serological and radiographic studies are critical to the workup.

Clinical Significance: The IPEH is a very interesting lesion of the adrenal gland, however, it is exceedingly rare and thus exclusion of more common and serious lesions must be done prior to the diagnosis of IPEH.

Holmes C, Akhras A, Schneider A, Yacoub JH, Picken M, Kabaker A. Adrenal Intravascular Papillary Endothelial Hyperplasia. World J Endoc Surg 2017;9(1):16-19.

Paragangliomas are neuroendocrine tumors and occur commonly in head and neck region and less frequently in the retroperitoneum. Multifocal paragangliomas are even rarer and highly suggestive of familial disease. To the best of our search, there are only two case reports of multiple retroperitoneal paragangliomas with no known familial association. This is the third report of this kind in the English literature.

A young adult with no significant past or family history presented with abdominal pain and anorexia. Abdominal examination revealed a soft nontender mass in the right hypochondrium. Contrast-enhanced computed tomography showed multiple retroperitoneal mass lesions. A clinicoradiological diagnosis of multicentric Castleman's disease/Lymphoma was made. Guided fine needle aspiration of the mass was suggestive of a neuroendocrine neoplasm. Tru-cut biopsy showed features of paraganglioma. Following this, the masses were excised and the diagnosis of paraganglioma was confirmed.

Multicentric retroperitoneal paragangliomas without any familial association are very rare with only two case reports in the English literature. Lack of symptoms makes the diagnosis difficult and also makes our case unique. Biopsy from paragangliomas and surgical intervention are known to cause life-threatening complications, such as profuse bleeding and abrupt changes in blood pressure. Hence, paragangliomas should be considered as a possibility, even if a remote one, in case of multicentric retroperitoneal tumors. This case also highlights the importance of cytology in the early diagnosis of retroperitoneal masses.

Singh A, Shikha D, Agarwal S, Khurana N, Jain SL, Hadke NS. Multiple Retroperitoneal Paragangliomas: An Uncommon Entity. World J Endoc Surg 2017;9(1):20-23.

Ruiz EC, Cebrián JMF, Vega L, Linacero S, Celi E, Quintáns A. Tertiary Hyperparathyroidism Secondary to X-linked Hypophosphatemic Rickets. World J Endoc Surg 2017;9(1):24-26.

We described the use of a hand-port assisted laparoscopic adrenalectomy for excising a large 10 cm vascular left adrenal pheochromocytoma. The useful technical tips and important pitfalls to avoid for a successful outcome are discussed in this article.

A 64-year-old man who was investigated for microalbuminuria was found to have a 10-cm left adrenal mass. Blood investigation and imaging confirmed it to be a pheochromocytoma.

Initial mobilization of the adrenal mass was performed laparoscopically using two 5-mm ports in the epigastric. While dissecting the inferomedial pedicle, the aberrant adrenal vessel was injured and resulted in torrential bleeding. A gelport for hand assistance was inserted as a salvage approach for hemostasis.

Hand-port assisted laparoscopic adrenalectomy is a very practical and easy-to-adopt technique that preserves the minimally invasive surgical advantages in patients with large adrenal masses.

Clinical significance: We advocate the use of hand-assisted laparoscopic adrenalectomy technique for complex pheochromocytoma as an alternative for surgeons with vast experience in laparoscopic adrenalectomy.

Lee DJK, Tan YP, Singaporewalla RM. Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review. World J Endoc Surg 2017;9(1):27-31.

Mayilvaganan S, Bothra S, Rashid M, Chekavar A, Vema AK, Agarwal A. Transection of Sternocleidomastoid for Selective Neck Dissection in Recurrent Papillary Thyroid Cancers. World J Endoc Surg 2017;9(1):32-34.

Jain V. Beahrs’ Triangle: The Surgical Anatomy. World J Endoc Surg 2017;9(1):35.