Written and medically reviewed by: Assoc. Prof. Cengiz Dibekoğlu, MD, General SurgeryLast updated:
Gastroesophageal Reflux (GERD) — Anti-Reflux Surgery
Nissen, Toupet, and Dor fundoplication with hiatal repair — for carefully selected proven GERD after objective testing.
Anti-reflux surgery reconstructs the valve mechanism, usually with a fundoplication and repair of any significant hiatal hernia. The best-known wrap is Nissen (360°). Selected patients may instead receive a partial wrap — Toupet (about 270° posterior) or Dor (anterior partial) — especially when esophageal motility is weaker or anatomy favors a softer valve. Surgery is considered for objectively proven GERD with severe esophagitis, large symptomatic hiatal hernia, persistent troublesome symptoms despite optimized medical therapy, or — after shared decision-making — preference against long-term medication in an appropriate candidate. Barrett’s esophagus alone is not an indication for anti-reflux surgery for cancer prevention. Laparoscopic or robotic approaches are common. Success tracks patient selection and manometric suitability more than incision size.
Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
- This educational figure shows: Anti-reflux surgery.
- Related figures on this page: Nissen (360°), Toupet (270° posterior), Dor (anterior partial).
Related educational figures
Tap a figure to enlarge.
Nissen (360°) Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
Nissen (360°)
Toupet (270° posterior) Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
Toupet (270° posterior)
Dor (anterior partial) Educational schematic. Some structures may be simplified or emphasized for clarity; not an exact anatomical depiction.
© Cengiz Dibekoğlu — illustrative; not for unauthorized use
Figure summary
Dor (anterior partial)
Who may be a candidate?
- Objectively confirmed GERD with troublesome breakthrough symptoms
- Large symptomatic hiatal hernias in fit surgical candidates
- Patients intolerant of long-term PPI therapy after shared decision-making
- Adequate motility profile for the planned wrap (Nissen, Toupet, or Dor)
Possible advantages
- Can reduce dependence on daily acid suppression in well-selected patients
- Addresses anatomic hernia component when present
- Wrap choice (full vs partial) can be matched to motility and anatomy
- Minimally invasive approaches for most elective cases
Limits & realistic expectations
- Gas-bloat, dysphagia, or wrap issues can occur — more often discussed with full wraps
- Not a cure-all for functional heartburn without reflux on testing
- Revisional surgery is more complex
- Lifestyle measures still matter postoperatively
Step-by-step overview
- 1
Confirm objective GERD
Endoscopy, pH/impedance testing, and manometry when they change the operative plan.
- 2
Review anatomy and motility
Hiatal hernia size, esophageal motility, and prior operations guide whether Nissen, Toupet, or Dor is more appropriate.
- 3
Shared decision-making
Compare continued medical therapy with expected benefits and risks of each wrap type.
- 4
Plan the operation
Hiatal repair plus wrap selection (Nissen 360°, Toupet ~270° posterior, or Dor anterior), and minimally invasive vs open access.
- 5
Postoperative follow-up
Staged diet, gas-bloat counseling, and clear instructions on when to call after discharge.
Key points
- Key note inside
When surgery is discussed
Objective GERD documentation comes first. Surgery may be considered for severe reflux esophagitis, large symptomatic hiatal hernia, persistent troublesome regurgitation or symptoms despite optimized medical therapy, or — after shared decision-making — long-term medication preference in an appropriate candidate. Barrett’s esophagus alone is not an indication for anti-reflux surgery for cancer prevention.
Preoperative testing
Endoscopy assesses esophagitis grade and Barrett’s changes. pH/impedance confirms reflux burden when symptoms and endoscopy do not align. Manometry maps motility before choosing among Nissen, Toupet, and Dor — a fundoplication should not be built on the wrong physiology.
Nissen fundoplication (360°)
The fundus wraps fully around the lower esophagus to create a strong mechanical valve. It is the classic and most familiar anti-reflux operation when motility supports a complete wrap. Temporary dysphagia and gas-bloat are discussed more often than with partial wraps.
Toupet (≈270° posterior partial)
A partial posterior wrap leaves the front of the esophagus uncovered. It is often considered when manometry suggests weaker esophageal motility and a softer valve may reduce swallowing trouble while still controlling reflux.
Dor (anterior partial)
An anterior partial fundoplication covers the front of the esophagus rather than a full circumferential cuff. It is used selectively for anatomy or combined procedures where an anterior wrap fits the plan better than Nissen or Toupet.
- Key note inside
Warning signs after surgery
Call promptly for inability to swallow liquids, worsening dysphagia, severe pain, fever, repeated vomiting, black stools, or shortness of breath. Mild early bloating and soft-food sticking are common early on; progressive or severe symptoms need assessment.
- Cannot swallow liquids
- Fever with worsening pain
- Repeated vomiting
- Black stools or major bleeding
- Key note inside
Important
This page is for education. It is not medical advice and does not replace a visit with your physician.
Frequently asked questions
Who is a candidate for anti-reflux surgery?
Objectively proven GERD with severe esophagitis, large symptomatic hiatal hernia, persistent symptoms despite optimized medical therapy, or — after counseling — preference against long-term medication in a suitable candidate. Barrett’s alone is not a cancer-prevention indication for surgery.
Nissen, Toupet, or Dor — how is the wrap chosen?
Nissen (full 360°) is the classic strong anti-reflux wrap when motility is suitable. Toupet (posterior partial, about 270°) and Dor (anterior partial) leave part of the esophagus uncovered and may reduce dysphagia risk in selected weaker-motility or anatomic settings. Manometry, symptom pattern, and surgical judgment decide — not a one-wrap-fits-all label.
What are common recovery themes?
Early walking, pain control, staged soft diet, temporary activity limits, and gas-bloat management are typical; exact timelines are individualized.
What warning signs after fundoplication need urgent review?
Inability to swallow liquids, progressive dysphagia, severe chest or abdominal pain, fever, repeated vomiting, black stools, or shortness of breath.
More chapters in this hub
GERD Symptoms
What patients notice — and which warning signs need urgent care
GERD Diagnosis
How clinicians confirm the problem and stage the next steps
GERD Treatment
Lifestyle, medicines, and surgery timing
Nutrition After Anti-Reflux Surgery
Staged diet after fundoplication
Achalasia
Dysphagia and manometry — not GERD
Appointment / info
This page is for education. It is not medical advice and does not replace a visit with your physician.
Medical editor: Assoc. Prof. Cengiz Dibekoğlu, MD · Last medically reviewed: August 2026 · English patient-education chapter.