Martha Maria Hospital in Munich, Germany is one of the worldwide leading hospitals for endocrine Surgery. Being a center for thyroid and parathyroid surgery our experience results from more than 29.000 procedures for thyroid diseases and more than 3000 procedures for parathyroid diseases over the last 20 years.

In addition, endocrine surgery is also performed for adrenal and pancreatic diseases.

Depending on the nature of the disease, surgery is performed minimally invasively or conventionally (open surgery).

We devote ourselves to providing maximal safety for our patients, to preventing typical complications and to maintaining a successful and functionally adequate therapy.

To avoid injuries of the vocal cords we are using the so-called neuromonitoring during  all procedures at the thyroid gland. 

Simultaneously, telepathology is available during surgery to  determine whether the removed tissue is benign or malignant.

Surgical activities

please check also pancreas  in  GI-Surgery
please check also adrenal gland in Minimally invasive surgery

Thyroid surgery     

Traditionally, thyroid surgery is the main focus in Martha-Maria Hospital. Using most advanced techniques we can minimize the typical complications of thyroid surgery such as injuries of the vocal cords with subsequent impairment of phonation, and of the parathyroid glands with subsequent calcium deficiency in the blood.

To avoid injuries of the vocal cords we always used to identify the nerves of the vocal cords during surgery.  In addition, since 1998 we are performing routinely  the so-called neuromonitoring of the vocal cord nerves during all surgical procedures at the thyroid and parathyroid glands. Worldwide we have the widest experience with this method.

Using this so-called neuromonitoring of the vocal cord nerves we are not only capable of identifying and sparing the nerve in its course, but also of testing its function with high reliability. Thus far, these procedures were not available for thyroid surgery.

Based on neuromonitoring we developed special operative strategies, particularly for problematic cases.

To avoid injuries of the parathyroid glands we also visualize them during surgery to spare them. If blood supply is compromised, single parathyroid glands will be removed immediately and will subsequently be re-implanted into the cervical muscles, thereby preserving their function.

To examine whether removed thyroid tissues are benign or malignant,  we can use telemedicine. Through it, we can communicate directly from the operating room with the pathologist on call (telepathology). Using telepathology the surgeon may gain precise information on the nature of the removed tissue without any time delay.

Besides patient safety and  functionally adequate surgery we are maximally devoted to achieving a scar formation which yields the best cosmetic result.

For this reason we use - whenever possible - very small skin incisions or a minimally invasive technique is being applied.

Parathyroid surgery     

The parathyroid glands are small organs more or less adjacent to the thyroid gland which are controlling the calcium metabolism of the body. Control is performed via the hormone of the parathyroid gland, the so-called parathormone.

Usually, surgery for parathyroid diseases will be indicated, if the production of the parathormone is too high. If this overproduction results from an enlarged parathyroid gland  for non-obvious reasons, the associated disease is named primary hyperparathyroidism. This disease either affects one gland (about 80% of cases), or two glands (about 2%) or all four glands (17%). Almost always this disease is benign, in rare cases there is a hereditary risk. Depending on the number of diseased glands we are selecting different surgical procedures.

It is important to leave sufficient healthy tissue of the parathyroid gland in place for maintaining the function of the calcium metabolism.  Simultaneously, however, all diseased tissue should be removed. Especially  this type of surgery requires a very experienced surgeon who is aware of the potential site variations of the parathyroid glands and who can recognize diseased tissue. This high degree of experience is provided in Martha-Maria Hospital due to the large numbers of cases performed.

Besides experience further special services are indispensable for parathyroid surgery, e.g. a potential cryo-conservation of parathyroid tissue. This tissue can be stored for years and may  - if required - be implanted into human muscle tissue after defrosting to resume its normal function.

Another recent procedure for parathyroid surgery is the intraoperative measurement of parathormone concentration, the so-called quick-parathormone-test. We are applying this test since 1998, and by using this test we can recognize already during the operation if surgery was successful.

Under certain conditions it is possible to perform also minimally invasive parathyroid surgery

A secondary overproduction of parathormone (e.g. in chronic renal failure or during calcium malabsorption) is named reactive hyperparathyroidism. In such case, always all four parathyroid glands are affected and enlarged. For therapy one removes all of them except a small residue  of normal size (subtotal parathyroidectomy), or one removes all cervical parathyroid glands and transplants a portion of the tissue into forearm muscle tissue during the same operation (total parathyroidectomy plus autologous transplantation). During this procedure cryo-conservation of parathyroid tissue is of particular importance for the patient.

A reactive hyperparathyroidism is most frequently found in patients on dialysis due to chronic kidney failure. In Martha-Maria hospital dialysis is available for in-patients during the whole stay in the affiliated dialysis unit.

Neuromonitoring     

Paralysis of the vocal cord nerves (recurrent laryngeal nerve paralysis= RLNP) is one of the dreaded complications of thyroid and parathyroid surgery. A one-sided RLNP causes an arrest of one vocal cord. Frequently you will then have a raucous voice. According to medical reports corresponding frequencies vary between less than one percent to more than 20% after a second or after multiple operations (surgery for recurrent disease).

Bilateral RLNP often leads to shortness of breath, a situation which eventually requires a tracheotomy.

Fortunately, the majority of RLNPs which occur after thyroid or parathyroid surgery, are reversible.

To keep the risk of RLNP as low as possible, we control the vocal cord nerve via neuromonitoring. To do so we use a probe during surgery to stimulate the vocal cord nerve electrically. At stimulation the muscle which is controlled by this nerve - in our case the musculus vocalis - will contract. It is located in the voice box and moves the vocal cord. Corresponding electric signals are registered by a probe which has been placed in this muscle, and these signals are transformed into acoustic signals. Thereby, it is possible to locate the vocal cord nerve and to control its intactness during surgery.

Telepathology     

Telepatholgy uses the telecommunication web and provides the possibility to present tissues to a pathologist for examination who is located several kilometers apart.  However, preparation and presentation of these tissues are still done in the operating room. In principle, the pathologist may reside in any place of the world.

The center part of this device is a microscope which is accessible from the operating room and which can be  navigated completely from the outside via a phone line. A pathologist sits on the opposite side in front of a monitor which displays microscope pictures which are transmitted via a connected video camera. The pathologist navigates the microscope in the operating room via a control system which resembles a joy stick. Data are transferred through an ISDN telephone network. After the surgeon has selected a tissue sample it is transferred as crude pre-cut section to a neighbouring room were instantaneous sections are done. Using a macrocamera the pathologist can examine the specimen which is displayed on his monitor, and he can select areas for detailed evaluation. The doctor in the operating room  - being quasi the long arm of the pathologist - prepares the corresponding parts. Using a frozen microtome at -28 degree Celsius he produces razor-thin layers from the coloured tissue which are placed on an object holder underneath the remote-controlled microscope. Actual instantaneous sections are done after another online connection with the pathologist has been established. From his place the pathologist navigates the microscope which moves across the specimen, and he may look at certain sections which are up to 40-times magnified. After a few minutes results are available which are communicated to the surgeon via phone. Using this important information he can plan the further process of the surgical procedure. We predominantly use this method in thyroid and parathyroid surgery, thereby cooperating with the Department of Pathology of the city hospital Munich-Harlaching (W.Nathrath, MD, Professor of Pathology). At the moment we perform daily up to 15 examinations by instantaneous section. About 12 to 15 minutes pass between the time when the specimen is harvested and the time the results are received. Thereby, we avoid unnecessary delays and save anaesthesia time.

Contact

	0049-(0)89-7276-224
	0049-(0)89-7276-233
	chirurgie.muenchen@martha-maria.de
	Krankenhaus Martha-Maria München Chirurgische Klinik Wolfratshauser Straße 109 D-81479 München Germany