Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy

Surg Endosc. 2017 Jul;31(7):3020-3027. doi: 10.1007/s00464-016-5330-y. Epub 2016 Nov 18.


Background: It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy.

Methods: All consecutive patients (N = 22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805 nm; filter: 825 nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes.

Results: ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203 ± 89 (125-331) and 207 ± 112 (130-356) s, respectively. The mean (range) fluorescence duration in these glands was 20.8 ± 6.0 (16.6-35.8) and 20.1 ± 7.3 (15.5-33.8) min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P = 0.048).

Conclusions: ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.

Keywords: Bilateral axillo-breast approach; Firefly technology; Indocyanine green fluorescence; Near infrared; Parathyroid glands; Robotic thyroidectomy.

MeSH terms

  • Adult
  • Carcinoma, Papillary / diagnostic imaging
  • Carcinoma, Papillary / surgery*
  • Case-Control Studies
  • Female
  • Humans
  • Indocyanine Green
  • Male
  • Middle Aged
  • Parathyroid Glands / diagnostic imaging
  • Parathyroidectomy / methods*
  • Postoperative Complications
  • Propensity Score
  • Prospective Studies
  • Robotic Surgical Procedures / methods*
  • Thyroid Cancer, Papillary
  • Thyroid Neoplasms / diagnostic imaging
  • Thyroid Neoplasms / surgery*
  • Young Adult


  • Indocyanine Green