Subtotal Parathyroidectomy Under Indocyanine Green Angiography

Area of Science:

• Endocrinology
• Surgical Oncology
• Nephrology

Background:

• Subtotal parathyroidectomy is indicated for secondary/tertiary hyperparathyroidism and primary hyperparathyroidism with multiglandular disease.
• A major complication of parathyroid surgery is transient or persistent hypoparathyroidism.
• Assessing parathyroid remnant vascularization is crucial to prevent postoperative hypoparathyroidism.

Purpose of the Study:

• To demonstrate a surgical technique for subtotal parathyroidectomy using indocyanine green (ICG) angiography.
• To intraoperatively assess the vascularization of the parathyroid remnant.
• To minimize the risk of definitive postoperative hypoparathyroidism.

Main Methods:

• A 64-year-old male patient with end-stage chronic kidney disease and severe hyperparathyroidism underwent subtotal parathyroidectomy.
• Indocyanine green (ICG) solution was injected intravenously to visualize parathyroid remnant perfusion using fluorescent imaging.
• The superior parathyroid glands were identified as candidates for subtotal resection, with clips applied to preserve vascular pedicles before ICG injection and assessment.

Main Results:

• Postoperative course was uneventful, with transient hypocalcemia managed with intravenous calcium.
• Pathologic examination revealed nodular hyperplasia in inferior glands and diffuse hyperplasia in superior glands.
• ICG angiography confirmed adequate perfusion of the preserved parathyroid remnant.

Conclusions:

• Subtotal parathyroidectomy with ICG angiography is a safe and reproducible technique.
• Intraoperative assessment of remnant vascularization with ICG angiography helps prevent definitive hypoparathyroidism.
• This technique is recommended when the necessary equipment is available.