Toupet fundoplication is a laparoscopic (keyhole) antireflux surgery in which the surgeon wraps the upper part of the stomach (the fundus) 270 degrees around the back of the lower esophagus and secures it in place, recreating a one-way valve that keeps stomach contents from flowing back up (Flores et al., Cochrane Database of Systematic Reviews, 2026). It is the most widely used partial fundoplication and is the natural counterpart to the Nissen fundoplication, which uses a complete 360-degree wrap.

The difference between a 270° partial wrap and a 360° complete wrap is the central decision in antireflux surgery. A large body of randomized evidence shows that Toupet achieves reflux control, quality-of-life improvement, and lower esophageal sphincter reinforcement comparable to Nissen, but with significantly lower rates of postoperative difficulty swallowing (dysphagia), gas-bloat syndrome, and inability to belch or vomit (Tian et al., PLoS One, 2015; Salman et al., Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 2023). A network meta-analysis of randomized trials found Toupet had roughly one-third the odds of dysphagia compared with Nissen (OR 0.285), while matching it on all other outcomes (Lee et al., Surgical Endoscopy, 2023).

Toupet is most often performed together with a hiatal hernia repair (crural closure), because most patients with significant reflux also have a hiatal hernia that must be fixed at the same time for durable results (Yadlapati et al., American Gastroenterological Association, 2022). Like all antireflux surgery, candidacy requires objective confirmation of pathologic reflux and exclusion of a motility disorder such as achalasia before proceeding (Yadlapati et al., American Gastroenterological Association, 2022).

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Reflux happens when the barrier between the esophagus and stomach — the lower esophageal sphincter (LES), often weakened or displaced by a hiatal hernia — fails to keep acid and stomach contents where they belong. Toupet fundoplication rebuilds this barrier mechanically (Gadalla et al., Surgical Endoscopy, 2025):

• Restoring anatomy: Any hiatal hernia is reduced, the esophagus is returned to its normal position in the abdomen, and the widened diaphragmatic opening (hiatus) is tightened with sutures (crural repair).

• Augmenting the valve: The fundus of the stomach is wrapped 270° around the posterior (back) three-quarters of the lower esophagus, leaving the front quarter uncovered. This reinforces and raises the pressure of the lower esophageal sphincter, re-creating a competent one-way valve (Gadalla et al., Surgical Endoscopy, 2025).

• Preserving physiologic function: Because the wrap is partial rather than complete, the reconstructed junction remains more distensible than after a Nissen wrap. This greater esophagogastric junction distensibility is the mechanical reason Toupet patients can still belch and vomit normally and have less gas-bloat and dysphagia (DeHaan et al., Surgical Endoscopy, 2017).

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• Effective, durable reflux control comparable to the Nissen gold standard, with equivalent symptom relief, quality-of-life improvement, and LES reinforcement (Tian et al., PLoS One, 2015; Salman et al., Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 2023).

• Significantly less postoperative dysphagia — in pooled randomized data, roughly 4.8% after Toupet versus 12.6% after Nissen (DeHaan et al., Surgical Endoscopy, 2017; Lee et al., Surgical Endoscopy, 2023).

• Less gas-bloat syndrome and preserved ability to belch and vomit, because the partial wrap vents swallowed air more readily (Tian et al., PLoS One, 2015; DeHaan et al., Surgical Endoscopy, 2017).

• Better preservation of esophageal motility, making it the preferred wrap for patients with weak or impaired peristalsis (Yadlapati et al., American Gastroenterological Association, 2022; Gadalla et al., Surgical Endoscopy, 2025).

• Freedom from daily acid-suppression medication for most patients, with high satisfaction compared with ongoing PPI therapy (Katz et al., American College of Gastroenterology, 2022).

• Minimally invasive approach — laparoscopic or robotic, with small incisions, short hospital stay, and quick recovery.

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Toupet fundoplication is appropriate for patients with objectively confirmed GERD who meet established candidacy criteria (Yadlapati et al., American Gastroenterological Association, 2022):

• Confirmed pathologic reflux — documented by ambulatory pH or pH-impedance monitoring, erosive esophagitis (LA grade C/D), or Barrett's esophagus.

• Symptoms inadequately controlled by, or a desire to stop, PPI therapy — including regurgitation-predominant reflux, which responds particularly well to surgery.

• Hiatal hernia requiring repair, which is addressed at the same operation.

• Impaired or weak esophageal motility — Toupet is specifically favored over Nissen when manometry shows esophageal hypomotility or reduced peristaltic reserve, to minimize the risk of postoperative dysphagia (Yadlapati et al., American Gastroenterological Association, 2022; Katz et al., American College of Gastroenterology, 2022).

Candidacy requires exclusion of achalasia and other major motility disorders by high-resolution manometry before surgery (Yadlapati et al., American Gastroenterological Association, 2022). Patients with severe esophagitis (grade C/D), Barrett's esophagus, or a hiatal hernia larger than 2 cm are generally better served by a fundoplication than by newer endoscopic options (Rabach et al., Current Opinion in Gastroenterology, 2019).

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Toupet fundoplication is performed under general anesthesia, almost always laparoscopically or robotically, through several small incisions (Gadalla et al., Surgical Endoscopy, 2025):

1. Access and exposure: A few small (5–12 mm) incisions are made; the liver is retracted to expose the esophageal hiatus.

1. Mobilization: The lower esophagus and gastric fundus are carefully mobilized, with division of the short gastric vessels as needed so the fundus can wrap without tension. The vagus nerves are identified and preserved.

1. Hiatal hernia repair: The hernia is reduced, an adequate length of intra-abdominal esophagus (ideally 2–3 cm) is achieved, and the diaphragmatic crura are approximated with sutures (crural repair) (Rattner, JOMI, Laparoscopic Paraesophageal Hernia Repair).

1. Creating the partial wrap: The fundus is passed behind the esophagus. A "shoeshine" maneuver confirms the stomach is oriented correctly and not twisted (Rattner, JOMI).

1. Securing the 270° wrap: The fundus is sutured to the right and left sides of the esophagus, leaving the anterior quarter of the esophagus uncovered — the defining feature of the Toupet wrap. Sutures may also anchor the wrap to the crura.

1. Closure: Instruments are removed and the small incisions are closed. The operation typically takes one to two hours.

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Toupet fundoplication is safe and well-tolerated, but as with any surgery there are risks (Köckerling et al., Hernia, 2024):

• Short-term/perioperative complications occur in roughly 6% of patients, with a complication-related reoperation rate around 1% (Köckerling et al., Hernia, 2024).

• Temporary dysphagia in the early weeks, usually from postoperative swelling, which typically resolves by around six months; persistent dysphagia is less common after Toupet than after Nissen (VanDruff et al., Surgical Endoscopy, 2026; Lee et al., Surgical Endoscopy, 2023).

• Gas-bloat symptoms and increased flatulence, generally milder than after a complete wrap (Tian et al., PLoS One, 2015).

• Recurrent reflux — roughly 6% at one year, with partial wraps carrying a potentially modestly higher long-term recurrence rate than complete wraps, though randomized data generally show no significant difference (Köckerling et al., Hernia, 2024; Katz et al., American College of Gastroenterology, 2022).

• Postoperative chest pain or pain on exertion, reported in a minority of patients after either wrap type (Köckerling et al., Hernia, 2024).

• Wrap disruption or hiatal hernia recurrence requiring revisional surgery in a small percentage over time.

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Most patients go home within one to two days. Recovery follows a predictable course:

• First 1–2 weeks: A staged diet — clear liquids advancing to full liquids and then soft foods — protects the healing wrap and accommodates normal postoperative swelling.

• Swallowing: Mild difficulty swallowing and a sensation of food "sticking" are common early and usually improve as swelling subsides; by six months, dysphagia scores typically return to baseline (VanDruff et al., Surgical Endoscopy, 2026).

• Activity: Light activity resumes within days; heavy lifting and strenuous exertion are generally restricted for several weeks to protect the crural repair.

• Return to work: Many patients return to desk work within one to two weeks.

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The large majority of patients achieve durable relief of heartburn and regurgitation and are able to stop daily acid-suppression medication (Katz et al., American College of Gastroenterology, 2022). Randomized and registry data show Toupet maintains reflux control comparable to Nissen over long-term follow-up, with reflux recurrence in the range of 13–17% over several years for both wrap types (Köckerling et al., Hernia, 2024). The trade-off remains consistent across studies: Toupet trades a potentially small increase in long-term reflux recurrence for a meaningful reduction in dysphagia and gas-bloat, which is why wrap selection is individualized to each patient's anatomy, motility, and symptom profile (Katz et al., American College of Gastroenterology, 2022; Gadalla et al., Surgical Endoscopy, 2025).

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Selecting the right antireflux operation — and the right wrap — is where experience matters most. Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, individualizes every antireflux procedure based on objective esophageal physiologic testing (high-resolution manometry and ambulatory pH-impedance monitoring), tailoring the choice between a Toupet partial wrap and a Nissen complete wrap to each patient's motility, anatomy, and symptom profile. This evidence-based, motility-preserving philosophy — reserving the complete wrap for those who need maximal reflux control and favoring the partial wrap when protecting swallowing function is paramount — delivers durable reflux relief while minimizing the dysphagia and gas-bloat that drive patient dissatisfaction after antireflux surgery.

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Choosing between a Toupet (partial) and Nissen (complete) wrap is the core antireflux decision, and current evidence supports a tailored approach rather than a one-size-fits-all gold standard (Köckerling et al., Hernia, 2024). The guiding principle: if the overriding priority is maximal reflux control, a Nissen may be favored; if minimizing the risk of dysphagia is the priority — particularly in patients with impaired esophageal motility — a Toupet is preferred (Köckerling et al., Hernia, 2024; Yadlapati et al., American Gastroenterological Association, 2022). Multi-society consensus guidelines from 2022 specifically note that partial fundoplication may benefit patients with esophageal dysmotility (Lee et al., Surgical Endoscopy, 2023). Regardless of wrap type, antireflux surgery is only appropriate after objective confirmation of pathologic GERD and exclusion of achalasia (Yadlapati et al., American Gastroenterological Association, 2022).

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If reflux recurs or dysphagia is severe and persistent, options include endoscopic dilation for stricture or a tight wrap, or revisional antireflux surgery — redo fundoplication (converting a partial to a complete wrap or revising a disrupted wrap), magnetic sphincter augmentation (LINX), or, in selected obese patients, conversion to Roux-en-Y gastric bypass as a salvage antireflux strategy (Yadlapati et al., American Gastroenterological Association, 2022). Because all recurrences requiring intervention are best managed at an experienced foregut center, revisional decisions should follow repeat objective testing.

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Antireflux surgery is generally covered when medical necessity is documented. Typical requirements include objective confirmation of GERD (abnormal pH study, erosive esophagitis, or Barrett's esophagus), a trial of medical therapy, and preoperative esophageal manometry to exclude a motility disorder and guide wrap selection (Yadlapati et al., American Gastroenterological Association, 2022). Documentation of a hiatal hernia and reflux-related complications supports authorization.

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• Esophageal workup: Upper endoscopy, ambulatory pH or pH-impedance monitoring, and high-resolution manometry to confirm pathologic reflux, assess motility, and exclude achalasia (Yadlapati et al., American Gastroenterological Association, 2022).

• Barium esophagram when a hiatal hernia needs anatomic characterization.

• Medication review and standard preoperative optimization.

• Dietary counseling for the staged postoperative diet.

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• Diet: Advance through a staged diet — clear liquids, full liquids, soft foods, then regular diet over several weeks — eating small, slow, well-chewed meals to protect the wrap during healing.

• Activity: Walk early to prevent blood clots; avoid heavy lifting and strenuous core exertion for several weeks to protect the crural repair.

• Follow-up: Scheduled visits to monitor swallowing and reflux control, with early reporting of persistent dysphagia so it can be addressed promptly.

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