**4.3 Treatment of recurrence**

The reported failure following laparoscopic Nissen fundoplication for GERD and paraesophageal hernia is between 2-33%. Although failure of fundoplication is unusual when performed by an experienced surgeon, wrap herniation ('slipped Nissen') is the most common mechanism of failure. Other causes of failure are represented by disrupted fundoplication, slipped fundoplication, crural stenosis, too tight wrap, misplaced fundoplication or twisted fundoplication. In carefully selected patients who have recurrent or persistent symptoms (heartburn, dysphagia, chest pain, regurgitation, asthma, hoarsness or laryngitis) after laparoscopic or open fundoplication a laparoscopic redo fundoplication can be safely performed by an experienced surgeon. The overall conversion rate of redo laparoscopic fundoplication is 10%. Complications occur in approximately 15%, slightly increasing with multiple redos. After redo laparoscopic fundoplication 70% of patients is GERD-related symptom free (Smith et al., 2005).
