Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial

Purpose

Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial.

Methods

After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation.

Results

One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006)

Conclusions

Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.     

腹腔镜Nissen胃底折叠术对胃食管反流病患者食管动力学的影响

目的通过食管高分辨率测压（high resolution manometry,HRM）对比胃食管反流病（gastroesophageal reflux disease,GERD）患者腹腔镜下Nissen胃底折叠术（laparoscopic Nissen fundoplication,LNF）前后食管动力学的改变情况,探讨手术的抗反流原理。 方法选取2014年6月至2016年7月,火箭军总医院73例连续住院的GERD患者,LNF术前1周内行包括HRM在内一系列术前评估,术后GERD症状明显缓解且吞咽困难等并发症已经消失时复查HRM。对手术前后2次HRM的9个食管动力学参数进行对比分析,并按术前是否存在食管裂孔疝进一步分组分析。 结果术后患者食管长度平均延长了（0.43±1.72）cm,腹腔内下食管括约肌长度平均延长了（1.20± 0.94）cm,术后患者下食管括约肌静息压平均增加了（5.99±7.79）mmHg（1 mmHg=0.133 kPa）,综合松弛压平均增加了（3.41±5.43）mmHg;远端收缩分数平均增加了（157.26±596.01）mmHg·s·cm,远端收缩延迟时间平均增加了（0.93±2.30）s;上述6个动力学参数与术前比较差异均有统计学意义（P=0.04,<0.01,<0.01,<0.01,0.03,<0.01）。而术后下食管括约肌长度、食管上括约肌压力和收缩前沿速度与术前相比差异无统计学意义（P=0.83,0.43,0.73）。食管长度、下食管括约肌长度和远端收缩分数在食管裂孔疝患者中较无食管裂孔疝患者改善更为显著（P<0.01,<0.01,<0.01）。 结论LNF主要通过延长腹腔内食管长度,增强下食管括约压力,增强食管的廓清功能,从而到达有效的抗反流作用。其中合并食管裂孔疝的患者较无食管裂孔疝患者术后上述食管动力学改善更为显著。     

Laparoscopic redo Nissen fundoplication in infants and children

From January 1994 to December 2004, 118 patients with recurrent gastroesophageal reflux disease (GERD) after fundoplication underwent laparoscopic redo Nissen fundoplication. The patients ranged in age from 6 months to 19 years (mean, 7 years), and weighed from 6.4 to 85 kg. Of the 118 patients, 64 had previous open fundoplications, 53 had previous laparoscopic fundoplications, and 19 had more than one previous fundoplication. All the procedures had been successfully completed laparoscopically. The average operative time was 100 min. The intraoperative complication rate was 1.1%. The average time to full feeding was 1.8 days, and the average hospital stay was 2.2 days. The postoperative complication rate was 3.6%. The wrap failure rate during an average follow-up period of 48 months was 6%. Laparoscopic redo Nissen fundoplication for a failed antireflux procedure is a safe and effective procedure. It has the same benefits as a primary laparoscopic Nissen for GERD, with low morbidity and a quicker recovery. Early follow-up evaluation suggests that the long-term outcome is superior to that associated with open redo fundoplication.     

Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial

Purpose

Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures.

Effects of laparoscopic Nissen fundoplication on esophageal motility

Background This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility. Methods This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2). Results Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery. Conclusion Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Fort Lauderdale, FL, 13–16 April 2005     

Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair

Background Benign esophageal pseudoachalasia is a rare condition. Discussion We report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented. Results Endoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen’s wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.     

腹腔镜Nissen胃底折叠术的临床疗效评价

目的:评价腹腔镜Nissen手术在治疗食管裂孔疝中的优越性。方法:应用腹腔镜行食管裂孔疝修补和胃底折叠术治疗31例食管裂孔疝患者。结果:本组患者手术均获成功,仅1例发生纵隔气肿。术后随访6个月~7年,临床症状完全消失,无一例复发。结论:腹腔镜食管裂孔疝修补和胃底折叠术具有患者创伤小、痛苦少、住院时间短等优点,是当今治疗食管裂孔疝手术的金标准。     

The respiratory advantage of laparoscopic Nissen fundoplication

Background/purpose

Laparoscopic Nissen fundoplication is replacing the open approach in the treatment of children with gastroesophageal reflux. The postoperative respiratory advantages seem obvious but remain unproven. The authors hypothesized that laparoscopic Nissen fundoplication provides postoperative respiratory advantages in neurologically normal children as well as those with mental retardation or profound neurologic impairment.

Methods

The charts of all laparoscopic Nissen fundoplications over a 4-year period were reviewed. Sixty-one laparoscopic procedures were compared with the most recent 61 consecutive open Nissen fundoplications. The following variables were reviewed: age, weight, gender, preexisting comorbidities, operating time, postoperative pulmonary complications, and length of stay. Categorical data were compared for significance utilizing χ² cross tabulation. Variables representing numerical data were compared by t test.

Results

Although there appeared to be a trend toward sicker patients in the open group, the laparoscopic group showed significantly improved rates of extubation, shorter recovery room stays, shorter durations of chest physiotherapy, fewer intensive care unit admissions, more rapid resumption of baseline feedings, and overall decreased length of stay (P < 0.05). Pulmonary benefits also were noted in the neurologically impaired population when analyzed separately.

Conclusions

Laparoscopic Nissen fundoplication confers a definable benefit with a significant pulmonary advantage in both neurologically normal children and those with neurologic impairment.     

The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication

Objective

There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication.

Methods

After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up.

Results

Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up.

Conclusions

Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.     

Effects of prior endoluminal gastroplication on subsequent laparoscopic Nissen fundoplication

Background The long-term results of endoluminal gastroplication (ELGP) for gastroesophageal reflux disease (GERD) are still under investigation. Laparoscopic Nissen fundoplication (LNF) has unquestionable results in the treatment of GERD and, therefore, it would be unfortunate to compromise this treatment option by performing alternative therapies such as ELGP. Methods Six patients underwent ELGP for the treatment of GERD symptoms. After symptoms returned, these patients elected to have a LNF. Results There was no sign of periesophagitis or intraperitoneal adhesion formation found at hiatal dissection that hindered or complicated the LNF procedure. Recent follow-up has shown that the patient’s GERD symptom scores have decreased, as expected after a de novo LNF. Conclusion ELGP does not alter the surgical dissection or results of a subsequent LNF.     

Causes of long-term dysphagia after laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Despite improvements in the technique of fundoplication, persistent dysphagia remains a significant cause of postoperative morbidity. METHOD: Causes of persistent postoperative dysphagia were analyzed in a consecutive series of 167 patients after laparoscopic Nissen fundoplication. Short gastric vessel division and its effect on postoperative dysphagia were analyzed. RESULTS: Follow-up was possible in 139 patients (83%). The mean follow-up period was 27 +/- 21 months. Nine patients (6%) had persistent (moderate to severe) dysphagia, and 33 patients (24%) had mild dysphagia. The satisfaction score among patients with persistent dysphagia was significantly lower than that in patients with mild dysphagia (P < 0.0002). On the other hand, the satisfaction rate among patients with mild dysphagia and those who are asymptomatic was similar. Manometry, performed in 7 of 9 persistent dysphagia patients revealed no difference in postoperative lower esophagus sphincter (LES) pressure and relaxation as compared with that in the control group (n = 52). Six of 9 patients with persistent dysphagia underwent a re-do antireflux procedure. Dysphagia as related to fundic mobilization (complete vs. partial) or bougie size (< 58 Fr. vs. > or = 58 Fr.) revealed no difference in the dysphagia ratings. CONCLUSIONS: Laparoscopic short Nissen fundoplication with or without fundic mobilization achieved an acceptable long-term dysphagia rate. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of persistent postoperative dysphagia.     

Quality of life before and after laparoscopic Nissen fundoplication

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder in the Western world. The acute disease can usually be managed by medical therapy. To prevent relapse, many patients require lifelong medication. In these patients, laparoscopic antireflux surgery offers a good alternative. The aim of this study was to evaluate the postoperative results and compare pre- and postoperative quality of life after laparoscopic Nissen fundoplication. METHODS: Clinical investigations, including esophageal manometry, pH monitoring, and endoscopy, and a previously validated Quality of Life Index, were performed before and a median of 41 month after antireflux surgery in 75 patients. RESULTS: After laparoscopic Nissen fundoplication, the percentage of total time with pH <4 decreased from 10.4% to 3.2% on 24-h pH monitoring. The mean pressure of the lower esophageal sphincter improved from 8.1 to 12.3 mmHg. Esophagitis healed in 63 of 66 patients in whom it was present prior to surgery. The overall Quality of Life Index improved significantly from 86 +/- 16 to 116 +/- 16. CONCLUSION: Laparoscopic fundoplication provides effective and durable relief of reflux in patients with GERD. The Quality of Life Index showed significant improvement after surgery.     

Feasibility of laparoscopic Nissen fundoplication as a day-case procedure

Background  The aim of this prospective double-cohort pilot study is to evaluate the feasibility and desirability of laparoscopic Nissen fundoplication (LNF) performed in day-care when compared with laparoscopic cholecystectomy (LC) in day-care. Methods  Patients who underwent a LNF in day-care were prospectively evaluated. LNF patients were treated according to LC in day-care protocol. Outcome parameters were EQ-5D, visual analogue scale (VAS), and patient satisfaction. Results  From October 2005 to March 2008, 22 patients underwent LNF and 48 patients LC in day-care. After LNF, 21 out of 22 (95%) patients were discharged the same day. Seven (32%) patients were seen postoperatively in the Emergency Department with dysphagia or pain and two (9%) patients were readmitted. After LC, 45 out of 48 (94%) patients were discharged the same day. Six (12.5%) patients were seen postoperatively in the Emergency Department because of wound infection or pain and three (6%) were readmitted. EQ-5D and VAS scores were significantly worse after LNF in day-care (repeated measurements, p < 0.0001 and p < 0.0001). In a telephone survey 66.7% preferred a short hospital stay over day-care surgery after LNF compared with 30.9% after LC (p = 0.011). Conclusions  LNF in day-care is feasible and safe, but postoperative pain scores are high and most prefer short hospital stay.     

Recurrence after laparoscopic and open Nissen fundoplication

Background: Laparoscopic Nissen fundoplication as treatment for gastroesophageal reflux disease (GERD) in adults has a reported recurrence rate of 2–17%. We investigated the rates and mechanisms of failure after laparoscopic Nissen fundoplication in children. Methods: All patients who underwent a laparoscopic Nissen fundoplication for GERD and who subsequently required a redo Nissen were reviewed (n = 15). The control group consisted of the most recent 15 patients who developed recurrent GER after an open Nissen, fundoplication. Results: Between 1994 and 2000, laparoscopic Nissen fundoplication was performed in 179 patients. Fifteen patients (8.7%) underwent revision. The mechanisms of failure were herniation in four patients, wrap dehiscence in four, a too-short wrap in three, a loosened wrap in two, and other reasons in two. The reoperation was performed laparoscopically in five patients (33%). The failure mechanisms were different in the open patients: eight were due to slipped wraps; three to dehiscences; and two to herniations. Conclusion: The failure rate after laparoscopic Nissen is acceptably low. A redo laparoscopic Nissen can be performed safely after an initial laparoscopic approach.     

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. Methods A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. Results In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 ± 5.2 mmHg (range, 6.0–30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% ± 8.3% (range, 70–100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett’s progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1–46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. Conclusion The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360° fundoplication should not be contraindicated for patients with severe esophageal dysmotility.     

Laparoscopic Collis gastroplasty and Nissen fundoplication

Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience, ∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of a minimally invasive approach. Received: 8 September 1997/Accepted: 17 December 1997     

Postoperative esophageal physiology studies may help to predict long-term symptoms following laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication is an established treatment for gastroesophageal reflux disease (GERD). Postoperative improvement in esophageal physiology can be indicative of successful surgery, but the degree to which it correlates with symptom control remains questionable. We have performed this study to assess the utility of postoperative esophageal physiology studies in predicting long-term symptomatic outcome. Methods Between August 1997 and August 2003, 145 patients with symptomatic GERD underwent laparoscopic Nissen fundoplication as part of a randomized trial. Four months after surgery patients were invited to have postoperative esophageal physiology studies. In November 2005, a postal questionnaire was sent to all patients in order to assess reflux symptomatology (DeMeester symptom score). Results Completed symptom questionnaires were returned by 108 patients (74%) after a median of 5.7 years postoperatively. Linear regression of manometry data showed a significant correlation between the level of postoperative neosphincter pressure either above or below the median and long-term scores for heartburn (p = 0.03), dysphagia (p = 0.02), regurgitation (p = 0.01), and total symptom score (p = 0.002). In contrast, there was no evidence of a significant correlation between results of postoperative esophageal pH studies and symptom scores. Conclusion Postoperative physiology studies, particularly manometry, may be predictive of long-term symptoms following laparoscopic Nissen fundoplication. Presented as an oral abstract on 20 April 2007 at SAGES 2007, Las Vegas, USA     

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

Introduction

The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population.

Methods

The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean ± SEM.

Results

Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups.

Conclusion

Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.     

腹腔镜胃底180°前折叠术治疗食管裂孔疝疗效分析

目的探讨腹腔镜食管裂孔疝修补联合胃底180°前折叠术治疗食管裂孔疝疾病的可行性和安全性。方法回顾性分析了沧州市中西医结合医院与天津南开医院2008年9月至2013年6月采用腹腔镜技术治疗的180例食管裂孔疝患者资料,其中30例应用补片修补裂孔,剩余患者丝线缝合裂孔,均加做胃底180°前折叠（Dor手术）。结果手术顺利,无中转开腹者。术后随访3～60个月,手术效果满意率92.31％,术后3个月复查胃镜、上消化道造影等检查基本恢复正常。其中7例患者术后早期出现轻度反酸、烧心症状,均在4个月内通过保守治疗好转,无复发病例,无严重吞咽困难病例。结论腹腔镜食管裂孔疝修补和胃底180°前折叠术治疗食管裂孔疝疾病有微创手术创伤小、恢复快、安全可行、疗效可靠等特点,值得临床广泛应用。     

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a costeffective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment.Hospital costs and charges of patients undergoing open (N=9) and laparoscopic (N=11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91–6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values ± standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups.Operative time (221±18 vs 165±12 min, P=0.033) was longer in the laparoscopic group, while hospital stay (5.8±02 vs 8.8±04 days, P<0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615±863 vs $15,891±921, P=0.247). Overall hospital charges were nearly identical ($26,634±1376 vs $27,189±1753, P=0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064±252 vs $4,283±380, P=0.001), sterile supplies ($6,214±508 vs $5,403±390), and anesthesia charges ($1,593±76 vs $1,122±95, P<0.001) were all greater in the laparoscopic group. This was offset by significantly lower hospital-room charges following laparoscopy ($5,098±355 vs $6,983±511, P=0.006).Laparoscopic Nissen fundoplication is not more expensive than its open counterpart. At present, laparoscopy results in higher operating-room charges which offsets savings from a shorter hospital stay. Improvements in technique and attention to limiting the cost of sterile supplies may ultimately result in a cost savings in favor of laparoscopy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994