This study has several interesting findings. Compared to ONF, LNF shortened the mean operating time and the mean overall operating room duration. The LNF group also required less morphine and dramatically shortened the mean hospital stay duration by more than four days. Furthermore, the total cost for LNF was 39% lower while no difference was seen in postoperative results between the two groups.

Three randomized trials comparing LNF and ONF in children have previously been published 6, 7, 10. All of them found that LNF was associated with significantly longer operating time than ONF. The study by Papandria et al. 10 also declared that the LNF group had longer overall operating room duration. In our study, however, laparoscopy was found to shorten both the operating time and the overall operating room duration. In the previously published studies, the mean operating times were 160 min 7, 150 min 6 and 173 min 10 in the LNF group, and 80 min 7 89 min 6 and 91 min 10 in the ONF group. Thus, our mean operating time for the LNF group was in line with the operating times in the previously published studies, although our data includes a learning curve for performing surgeons, as the LNF technique was introduced at our centre during this study. However, our mean operating time for the ONF group was substantially longer than reported in the previous studies.

ONF, however, had been performed for several years before the first patients in our study were operated, and consequently two of the surgeons were already well experienced with the operative technique. The third surgeon started performing ONFs during the study period, wherefore that learning curve is included in the ONF group. Nevertheless, it should be noted that all surgeons performing the LNFs in our study were already experienced laparoscopists when they started with the LNFs. The previous laparoscopic experience among the surgeons might explain our short operating times, despite the included learning curve for LNF. One factor that possibly could affect our results is that four different surgeons performed the operations. Consequently, the surgeons’ individual skills and rapidity could cause the variation in time. On the other hand, two of the four surgeons performed both the ONFs and the LNFs, hence the individual factor should not be the only cause for the difference in operating time and overall operating room duration. Furthermore, different surgeons have also performed the fundoplications in the three previous studies. This additionally confirms the theory that the individual skill of the surgeon should not affect the results to a great extent.

Moreover, another important factor to consider is that our study was retrospective. This caused difficulty in identifying the correct operating times and overall operating room durations, especially for the patients who underwent simultaneous operations or procedures in connection with the Nissen fundoplication. This was particularly difficult for the operations executed before the autumn of 2016 since a new electronic system for registration of surgery was introduced at our hospital. Consequently, this would mainly affect the operating times and overall operating room durations for the ONF group since these operations were all executed before 2016 and 71% of the patients in the ONF group underwent simultaneous operations or procedures, in comparison with 44% in the LNF group. Thus, this could contribute to the difference in operating time and overall operating room duration between the ONF and LNF group in our study.

It is well-recognized among surgeons that laparoscopic surgery in general is associated with shorter postoperative hospital stay 11. In this study, LNF shortened the hospital stay by 4.3 days compared to ONF. In the previous publications, the median hospital stay was 5.0, 7.0, and 6.0 days, respectively, for the LNF group and 4.5, 7.5, and 4.0 days for the ONF group 6, 7, 10. Accordingly, our study is from what we know the only study demonstrating a dramatically shorter hospital stay for LNF, due to a more rapid patient recovery.

Our study also demonstrates decreased costs for the laparoscopy group. Previous studies 6, 7 did not analyze the costs of GERD surgery. One study found higher operating room costs for LNF, but no difference in total hospital charges between the groups 10.

The main reason for the distinct difference in mean total hospital charges between the two groups in our study is due to the shorter hospital stay for the LNF group. It was also a slightly higher proportion of patients who needed intensive care after ONF, which also increased the costs for that group. Even though the surgical material and equipment were more expensive for LNF, this difference was negligible in the full cost summation.

In contrast to the previous randomized trials 7, 10, LNF significantly decreased the mean morphine requirements in our study. Hence, our study seems to be the first study published during the last decade that has registered less use of morphine after LNF. It is well-recognized among surgeons that laparoscopy in general is associated with less postoperative pain 12.

In terms of complications after the operation, the previously published studies have presented ambiguous results. Retching was significantly more common after ONF 7, and the difference still remained after four years in the follow-up study 13. No difference was seen in early complications between the groups 6, 10, whereas a follow-up study 4 registered both a higher recurrence rate of GERD and a higher rate of reoperation after LNF. As to our study, no significant difference was seen between the groups in the incidence of both postoperative and post-discharge complications. Postoperative investigation was only performed if the patient showed symptoms of recurrence of GERD or was part of a follow-up program for another medical condition (for example long gap esophageal atresia). Only one patient in the LNF group suffered from symptoms of GERD and this patient was also diagnosed with recurrence and re-operated six months after the initial Nissen fundoplication. Of the patients suffering from symptoms of GERD in the ONF group, only one patient was diagnosed with a recurrence of GERD by pH-monitoring.