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Since the development of laparoscopic fundo-plication, 14 years ago, many individuals with severe gastroesophageal reflux disease (GERD) have undergone laparoscopic fundoplication to free themselves from medication dependence or side effects, because medical therapy was incompletely effective, to treat extraesophageal reflux symptoms and/or to treat reflux complications including esophageal stricture, aspiration, bleeding, and Barrett's esophagus.

The most popular laparoscopic procedures performed in North America have been the total fundoplication (Nissen fundoplication) and the partial, 270° posterior fundoplication (Toupet fundoplication). In other parts of the world, anterior fundoplication (Dor or Watson fundoplication) has also been popular. When fundo-plication is performed through a laparotomy or thoracotomy, recurrent symptoms or new troublesome symptoms have been reported in 9-30% of patients.1,2 Laparoscopic fundoplica-tion has been associated with failure rates ranging from 2 to 17%, depending on how failure is defined.3,4 The lower failure rates reported for laparoscopic fundoplication may reflect the fact that follow-up for these procedures has generally been shorter than that for open anti-reflux surgery.

The taxonomy of failed anti-reflux surgery can be based on symptoms (e.g.,heartburn, dys-phagia, gas bloat) or it may be based on the anatomy of failure, using a description of how the anatomy detected deviates from the ideal. For a surgeon, looking for defects that can be fixed, the anatomic description of failure is preferable. Kenneth DeVault discusses postoperative symptoms that are not related to anatomic fundoplication failure in Chapter 9. The anatomy or failure includes four commonly described anatomic problems,previously described with open surgery. These problems are: 1) slipped or misplaced fundoplication, 2) disrupted fundoplication, 3) herniated fundoplication, and 4) fundoplication that is too tight or too long.5 Laparoscopic fundoplication has been associated with two new anatomic problems, the two-compartment stomach, and the twisted fundoplication.6

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