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On a long-term evaluation, we feel that laparoscopic Nissen fundoplication is able to reproduce the results of open fundoplication as demonstrated in some studies. Our recent study of 100 patients at 10 years after laparoscopic fundoplication demonstrates a 90% rate of reflux control, which is comparable to the open long term results (paper submitted to publication). Some randomized short term trials have demonstrate that after open operations, there are statistically more complains about scars. The other parameters seem to be equivalent: control of symptoms, side effects. But, we must keep in mind that these results are obtained, in the laparoscopic group, with a reduced mortality and morbidity rate, shorter hospital stay and sick leave and a lower incidence of incisional complications. There is also, a substantial reduction in the rate of incidental splenectomies, as they are reported in the open series (0–8%). In summary, if long-term series confirm the results obtained in dedicated centres, laparoscopic Nissen fundoplication should become the “gold standard” of treatment for gastro -oesophageal reflux disease in appropriately investigated and selected patients.

Toupet described his technique of fundoplication in 1963 [ 1 ]. He had little clinical experience, but saw the importance of a partial wrap to avoid postoperative dysphagia. He recommended closure of the hiatus only in case of large hernias and never divided the short gastric vessels. If we talk about a Toupet procedure today, we mean a posterior partial fundoplication. In contrary to his original technique we have learned that hiatal closure is important to avoid recurrent hernia and that the wrap can be tailored more nicely, if the short gastric vessels are divided. This modern adaptation of Toupet’s operation is a very successful tool to treat gastrooesophageal reflux disease.

With the aim of optimising the outcome of antireflux surgery, the surgeon has to perform and master a delicate act of balance on the choice between various fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated mechanical side-effects leading to symptoms relating to the relative obstruction in the gastroesophageal junction and the inability to vent air from the stomach and the sequelae that follow. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without compromising with the level of reflux control and can therefore be generally recommended. Some anterior partial fundoplication present very promising results but confirmative studies are warranted.

Despite the fact that the majority of patients who undergo laparoscopic antireflux surgery have a good or excellent clinical outcome, a small proportion of patients develop a significant complication, side effect or recurrent reflux during postoperative followup. The management of these patients is complex. If problems occur in the immediate post-operative period, then early laparoscopic re-exploration should be considered, as many problems are easily be corrected within a week of the original procedure. Patients who develop problems during later followup should be fully reinvestigated, and non-operative treatment options are initially recommended, as many of the early side effects resolve with conservative management. Endoscopy and dilatation can be helpful at this stage. If problems persist beyond 12 months, then reoperation can be considered in patients with persistent dysphagia, symptomatic recurrent hiatus hernia, or recurrent reflux which is poorly controlled with medication. However, further surgery is unlikely to be help patients with persistent “wind-related” side effects.