Reactive hyperperfusion after short gastric artery division: a real-time indocyanine green fluorescence-guided approach to laparoscopic fundoplication - a case report.

INTRODUCTION: Fundoplication is an effective surgical treatment for gastroesophageal reflux disease, but postoperative dysphagia remains a common complication; intraoperative use of indocyanine green (ICG) fluorescence imaging allows real-time assessment of perfusion and guides surgical decision-making. CASE PRESENTATION: A 38-year-old male underwent laparoscopic hiatus hernia repair and fundoplication for persistent reflux symptoms despite maximal medical therapy. ICG was administered intravenously at three time points: after port placement, following division of the short gastric arteries, and during wrap formation. After division of the short gastric arteries, a bright orange fluorescence was observed in the stomach fundus, indicating reactive hyperemia. This could suggest an autoregulatory response to maintain perfusion. The patient remained symptomatically well without dysphagia or reflux at 6-month follow-up. DISCUSSION: The real-time change in perfusion was then used to guide the formation of the fundoplication, and final imaging confirmed adequate vascularity of the wrap without compromising the anti-reflux effect of the surgery. CONCLUSION: ICG fluorescence imaging is a safe and effective adjunct to intraoperative assessment of gastric perfusion during laparoscopic fundoplication, serves as a valuable training tool for guiding wrap construction, and may prevent postoperative dysphagia.