Introduction 1 2 2 Materials and Methods Between January 1993 and August 2002, 400 patients (262 males, 138 females) [mean age: 42.9 years (range 9–86)] underwent laparoscopic fundoplication in a District General Hospital. All procedures were performed or supervised by a dedicated upper gastrointestinal surgeon. Several trainees became the primary surgeons later in the series under direct supervision once they were deemed to have the appropriate laparoscopic skills. The indications for operation were: symptomatic GERD despite prolonged medical therapy; intolerance of medical therapy due to side effects; and volume regurgitation or patient preference for surgery. Data were collected prospectively on a handheld computer database (Psion, Psion Ltd., England). All patients underwent preoperative endoscopy and 24 h ambulatory esophageal pH monitoring. After the first 75 cases, all patients also underwent stationary esophageal manometry using a standardized technique. 3 The overall patient group was divided into eight cohorts of 50 consecutive patients. These cohorts were analyzed separately to compare the following: (1) patient demographics, (2) preoperative symptom length, (3) operative time, (4) length of postoperative hospital stay, (5) conversion to open operation, (6) reoperation rate, (7) postoperative dilatation rate, and (8) perioperative mortality or other early (within 6 months) postoperative complications. Results 1 1 Table 1 Demographics and Length of Preoperative Symptoms in Patients Undergoing Fundoplication for GERD   Patient Numbers 1–50 51–100 101–150 151–200 201–250 251–300 301–350 351–400 Time period to accrue cohort (months) 29 21 12 11 11 12 11 10 Mean age (years) (range) 36.3 (13–70) 41.6 (9–82) 43.9 (13–64) 44.5 (12–86) 44.3 (15–66) 43.9 (17–66) 45.4 (18–74) 45.1 (15–81) Sex (M:F) 34:16 38:12 28:22 32:18 29:21 29:21 34:16 35:15 Mean weight (kg) (range) 71.1 (44–102) 75.7 (29–98) 76.1 (49–104) 74.3 (30–102) 79.5 (51–120) 79.3 (44–103) 78 (48–103) 80.4 (53–100) Mean preoperative symptomatic period (months) (range) 91 (8–420) 85 (6–540) 106 (3–480) 92 (4–516) 106 (4–430) 96 (12–360) 141 (6–1,152) 140 (4–1,152) Figure 1 Showing operative conversions to open procedure, rates of reoperation, and rates of dilatation in patients undergoing laparoscopic fundoplication for GERD.  1 Conversions to Open Operation The conversion rate in the first cohort of 50 patients was 14%. Compared to this, only one conversion was required in the last 250 patients in the series, and this was necessitated by equipment failure rather than surgical difficulties. Other conversions were undertaken for hemorrhage from short gastric vessels (seven patients), port-site bleeding (one patient), splenic bleeding (one patient), difficult access (two patient), instrumental esophageal perforation (one patient), and adhesions from previous surgery (two patients). Patients Needing Postoperative Dilatations In the first 50 patients, 8 of them (16%) needed endoscopic balloon dilatation for persistent dysphagia or gas bloat syndrome between 10 days and 3 months postoperatively. They were dilated between one and three times. Nine patients (18%) were dilated in the second cohort between 9 days and 10 months postoperatively on one to four occasions. In the third cohort, six patients (12%) underwent dilatation between 1 week and 7 months, whereas in the fourth cohort, five patients (10%) were dilated between 3 weeks and 2 months postoperatively. They were all dilated once or twice. Two patients (4%) had two dilatations each between 2 and 9 months in the fifth cohort. No dilatations were needed by the last 150 patients to undergo laparoscopic fundoplication. Patients Needing Reoperation 1 2 Table 2 Total Number and Timing of Patients Undergoing Reoperation after Laparoscopic Fundoplication Cause of Reoperation Total Number of patients Early (within 3 months) Late (after 3 months) Mediastinal wrap herniation 16 1 15 Persistent reflux 1  1 Dysphagia despite dilatation 2 1 1 Gas bloat 3  3 Perforation of wrap 1 1  Port-site hernia 1  1 In the first cohort, five patients underwent reoperation for mediastinal “wrap” herniation between 9 and 80 months postoperatively. Two patients required revisional surgery; one underwent a Watson fundoplication, whereas the other undertook a redo Nissen fundoplication at 2 and 6 months, respectively, for persistent dysphagia failing to respond to endoscopic dilatations. One reoperation for “wrap” herniation was attempted laparoscopically but was converted to an open procedure. All other reoperations were carried out as open procedures. In the second cohort, three patients were reoperated on "for mediastinal “wrap” herniation and wrap disruption at 2, 30, and 47 months postoperatively: one by open surgery and two laparoscopically. One patient underwent laparoscopic conversion of a 360° to 270° “wrap” for “gas bloat” at 11 months despite two endoscopic “wrap” dilatations. There was one reoperation in the third cohort of patients for gas bloat 92 months later. The wrap was found to be mildly attenuated and was taken down laparoscopically. In the fourth cohort, one patient underwent laparoscopic conversion to a 270° “wrap” for “gas bloat” syndrome 12 months later, and one patient was converted from a 270° to a 360° wrap for a persistent reflux. Two patients underwent open reoperations in the fifth cohort: one for a perforation of the “wrap” at 4 days, the other for a port-site hernia repair at 9 months. In the sixth cohort, two patients underwent a redo LNF for wrap herniation and disruption at 23 and 36 months postoperatively. In the seventh cohort, two patients were found to have a wrap herniation, and one patient was found to have a large crural defect with wrap herniation at 18, 19, and 23 months, respectively. All underwent redo LNF; the patient with the large crural defect had a hiatal mesh placed. In the last cohort, three patients underwent redo LNF (two with hiatal mesh placement) for wrap herniation at 20, 27, and 36 months postoperatively. Discussion 4 5 6 7 Before the commencement of this study, the surgeon had a 6-year experience with open fundoplications. In the early 1990s, formal courses were not available to learn laparoscopic fundoplication: consequently, the surgeons pioneering this procedure were mentored for the first few cases. After this, the surgeon would operate independently. 8 9 2 10 6 11 12 12 13 13 14 Two patients had undergone reoperation for gas bloat syndrome: both were converted to a 270° posterior wrap and are now either asymptomatic or mildly symptomatic. 15 16 17 16 18 19 16 20 21 22 23 24 25 26 25 Our results show a decreasing trend in operative time, postoperative hospital stay, conversion rate, postoperative dilatation rate, and reoperation rate with increasing surgical experience and improved technology. Another factor in this improvement may be due to the increased frequency with which this procedure was performed with time. Conclusion Dysphagia is the Achilles’ heel of laparoscopic antireflux surgery. To avoid this, the authors have routinely divided the short gastric vessels. This has led to an increased rate of conversion owing to hemorrhage especially during the period when individual ligaclips were used. Short gastric vessel division may, in addition, increase the rate of wrap herniation and clip or thermal injury to the gastric fundus leading to perforation. 27 2 28 29 When introducing complex techniques, surgeons tend to underestimate the learning curve: both of themselves and of their institution. Only by maintaining prospective data can these problems be identified and recognized.