Indocyanine Green-guided Subtotal Parathyroidectomy in Severe Secondary Hyperparathyroidism with Negative Preoperative Localization: A Case Report

Abstract

Background: Secondary hyperparathyroidism in patients receiving dialysis commonly involves multigland parathyroid hyperplasia, which can limit the reliability of preoperative localisation and complicate surgical planning. This case describes the use of indocyanine green fluorescence during subtotal parathyroidectomy when ultrasonography and sestamibi scintigraphy were non-localising. Case Presentation: A patient with end-stage kidney disease on maintenance haemodialysis had severe secondary hyperparathyroidism with a preoperative intact parathyroid hormone level of 1400 pg/mL. Preoperative neck ultrasonography and sestamibi scintigraphy did not localise abnormal parathyroid glands. Bilateral neck exploration identified all four glands. Both left parathyroid glands and the right inferior gland were enlarged and were excised. The right superior gland was the least enlarged, retained an intact vascular pedicle, and showed good perfusion on indocyanine green fluorescence; it was therefore preserved as the remnant. Intraoperative intact parathyroid hormone decreased to 400 pg/mL, representing a 71% reduction. Histopathological examination confirmed parathyroid hyperplasia. Postoperatively, the patient experienced one episode of tingling in the fingers and toes, which settled with oral calcium supplementation. Conclusion: Negative preoperative localisation did not prevent identification of all four glands during bilateral exploration. In this case, indocyanine green fluorescence provided an adjunctive assessment of remnant perfusion during subtotal parathyroidectomy, while postoperative biochemical and clinical monitoring remained necessary.