Autotransplantation of the Parathyroid Glands in Thyroidectomy: The Role of Autofluorescence and Indocyanine Green

Devascularization of the parathyroid glands (PGs) during total thyroidectomy (TT) is the cause of post-surgical parathyroprival hypocalcemia. Safeguarding the anatomical integrity and vascularity of the PGs primarily requires an experienced surgeon. The combined use of magnification loupes (2.5× or 3.5×) with an ultrasound/radiofrequency device or bipolar forceps is also helpful. Near-infrared autofluorescence imaging may provide additional support in the recognition of the PGs during TT. Finally, the intravenous injection of indocyanine green (ICG) can be useful to verify the good vascularization of the PGs, even though there are still conflicting views on the clear clinical benefit that may justify routine use of this technique. A PG that remains accidentally devascularized must be reimplanted. The gland should be fragmented into 1 × 2-mm segments to maximize its contact surface with the muscle pocket. The most commonly used sites for reimplantation are the brachioradial muscle and, preferably, the sternocleidomastoid muscle. PG transplantation is an effective solution for ensuring post-thyroidectomy normocalcemia; however, the main objective is to preserve the anatomical and vascular integrity of all the PGs by means of an accurate and gentle surgical gesture.