Introduction

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. 36% to 44% of the western adult population experience heartburn at least once a month, 14% weekly, and 7% once a day.
The most important factor in the pathogenesis of reflux disease is malfunction of the lower esophageal sphincter (LES); additional factors are esophageal dysmotility and delayed gastric emptying. The function of the LES barrier depends upon the mechanical effect of sphincter pressure, overall length, and the intra-abdominal length. From a clinical perspective, mechanical incompetence of the sphincter occurs when one or more of these components fail. The complications of GERD are stricture, hemorrhage, perforation, aspiration, reflux-related asthma and developing a columnar lining, Barrett's esophagus. Barrett's has a malignant potential.
GERD can be treated medically or surgically. Since the availability of PPI's there has been the possibility to cure esophagitis in more than 60% of patients, but there is also a relapse rate of higher than 40% after cessation of PPI's. In 1956 Rudolf Nissen described a simple surgical technique for an antireflux procedure. The so-called "floppy Nissen" was described by P. E. Donahue in 1977, in which a looser, shorter wrap was created. The partial posterior fundoplication was described by P. Boutelier and G. Jonsell as an alternative maneuver to treat gastroesophageal reflux. This has been called the Toupet fundoplication. In 1991 Dallemagne published the first data on the laparoscopic procedure. Since then several large series have been presented. Using the laparoscopic procedure the mortality and morbidity of antireflux surgery are significantly decreased. Because of this, fundoplication has received a fresh impetus for the treatment of patients suffering from severe GERD.