Novel Fluorescence-Guided Gastric Calibration Tube in Robotic Paraesophageal Hernia Repair

Background: Fluorescence-guided (FG) surgery using near-infrared imaging has been adopted to enhance intraoperative visualization in multiple surgical fields. In foregut surgery, calibration tubes are routinely used to calibrate crural closure but due to limited visibility carry a risk of iatrogenic injury, including esophageal or gastric perforation. Techniques that improve visualization of these devices may support safer intraoperative management. Case Presentation: A 75-year-old woman with a symptomatic paraesophageal hiatal hernia and partial gastric volvulus underwent robotic paraesophageal hiatal hernia repair with Toupet fundoplication. A FG gastric calibration tube (size 40 Fr, Endolumik Inc.), was inserted under near-infrared visualization and advanced down the esophagus and into the stomach. The device was used to (1) evacuate gastric contents, (2) guide tube positioning past the gastroesophageal junction, (3) inform mediastinal dissection/esophageal mobilization, (4) enable FG measuring of the length of esophageal mobilization below the diaphragm, and (5) calibrate both crural closure and fundoplication. The procedure was completed without intraoperative complications. The patient was discharged on postoperative day 1 and reported resolution of dysphagia at 8-week follow-up. Discussion: This case demonstrates the feasibility of FG calibration during robotic paraesophageal hernia repair. Continuous visualization of the calibration device provided an additional intraoperative reference during dissection in the setting of distorted anatomy. This approach may offer improved orientation compared with conventional calibration techniques, although its effect on clinical outcomes remains unknown.