Feasibility of intraoperative force quantification during robotic paraesophageal hernia repair: a prospective case series using integrated force-sensing technology.

BACKGROUND

Paraesophageal hernia repair (PEHR) is associated with high complication rates and 5-year recurrence rates of 30%-66%, with excessive tissue tension and trauma hypothesized as key contributors. However, intraoperative assessment remains qualitative, relying on surgeon perception rather than objective measurement. This study evaluates the feasibility of applying integrated force-sensing robotic technology to perform prospective, phase-segmented analysis of intraoperative tissue forces during PEHR and characterize force variability across defined operative phases.

METHODS

A prospective evaluation of integrated force-sensing technology was conducted across nine consecutive robotic PEHRs performed at a single academic center on the da Vinci 5 robotic platform. Force data were collected from two Cadiere forceps and one Mega SutureCut needle driver. Operative workflow was segmented a priori into four biomechanically relevant phases: mediastinal dissection, crural tension assessment, cruroplasty, and fundoplication. Primary outcomes included mean force per phase (Newtons) and variability across cases. To assess the discriminative capacity of the force measurement framework, exploratory between-case comparisons were performed using two-tailed t-tests with Cohen's d effect size estimation against a designated low-complexity reference case. All cases were performed by fellowship-trained robotic foregut surgeons using a standardized technique with uniform haptic sensitivity settings.

RESULTS

Force data were successfully captured across all nine cases for all operative phases performed in each case, with 832-2,297 measurements per phase. Distinct phase-specific force profiles were observed: mediastinal dissection (2.00-3.04N), crural tension assessment (1.50-3.35N), cruroplasty suturing (1.68-3.58N), and fundoplication (1.96-2.97N), which demonstrated the greatest consistency. Exploratory comparisons demonstrated that the force measurement framework detected statistically distinguishable force profiles between cases of varying complexity (p < 0.001, Cohen's d: 0.21-0.30), including among both complicated and uncomplicated cases. Five patients experienced perioperative complications, including pleural injuries, dysphagia, and one recurrence.

CONCLUSION

Quantification of phase-specific intraoperative forces during robotic PEHR is feasible using integrated force-sensing technology. Observed variability across operative phases and the ability to detect distinguishable force profiles across cases of varying complexity support further investigation to define clinically meaningful force thresholds and potential applications in surgical standardization and training.