André Toupet, who today lives in retirement in Paris, is a singular example of a 19th-century-style gentleman surgeon whose contributions in the 20th century remain an important part of our surgical practice. These include the introduction of more than 20 surgical instruments and the description of more than 40 surgical procedures. Most of these innovations dealt with diseases of the liver and the large intestine, the latter being his major area of interest. ^1–10 However, he is recognized primarily for the antireflux procedure that bears his name. ¹¹

Today, the surgical treatment of chronic gastroesophageal reflux disease (GERD) continues to stimulate controversy, as evidenced by ongoing investigations comparing the efficacy of a 360° fundic wrap (Nissen procedure) with that of the Toupet 180° posterior wrap. ^12–17 Overall, the Nissen fundoplication has gained favor as the surgical procedure of choice for medically intractable GERD. ^18,19 However, some authors advocate the Toupet repair as a routine operation based on evidence that it may yield less postoperative dysphagia than the Nissen fundoplication. ^{12–14,20–26} Others reserve it for reflux patients with weak esophageal motility. ^27–29 Fueling this debate, recent data suggest that the Toupet fundoplication may be a less adequate antireflux operation, as shown by a higher symptomatic recurrence rate. ^30,31

There have been several barriers to the understanding and appropriate clinical application of the Toupet fundoplication. Most importantly, Toupet’s original technical description was never published in the English literature. Consequently, what is commonly referred to as a “Toupet procedure” incorrectly includes the closure of the crura and the division of the short gastric vessels before the fundoplication, which leads to a loose and incompetent wrap. This differs from the original technique and may contribute to inferior results. The second factor may relate to André Toupet himself.

Despite his great innovative ability, intense observational skills, and a strong desire to improve on established techniques, Toupet was not widely recognized by the surgical community. He failed to scrutinize his techniques scientifically and relied instead on his own clinical observations. Further, Toupet shunned the academic setting, preferring to work alone in private practice. This hurt his career and drew heavy criticism from the influential surgeons of his time. Ultimately, Toupet’s moment of triumph was dashed at the French Academy of Surgery in 1963, for on presentation of the original technique of posterior fundoplication, his work was belittled as mere “cadaveric experimentation.”¹¹

We have a unique opportunity to shed light on a surgical procedure that is perhaps better known in name than in practice. In doing so, we also discover the rich life of the man behind the operation. In this paper we provide, for the first time, the original Toupet report translated verbatim into English as well as the biography of a great surgical technician as relayed by Toupet himself.

Toupet descended from a family of prominent physicians in Paris. His grandfather was a general practitioner and served as the personal physician to the French royalty, the Duc d’Aunale, fourth son and heir to King Louis Philippe of France, at the end of the 19th century. He often accompanied the Duke on French military expeditions. He was also an avid biologist and spent time studying beer molds. During the time of Pasteur, he observed that molds had a negative influence on the growth of staphylococci. He called these substances, which are closely related to penicillin, staphylase and mycolysine.

Toupet was born on January 6, 1915, in Paris to Rene Toupet and Estelle Dubois. His father had a great influence on his life (Fig. 1). Rene Toupet was a general surgeon who distinguished himself early in his career by being appointed top resident at the young age of 21. After the war, Rene Toupet enjoyed a successful private practice in Paris but never pursued an academic career. Thus, he never held the prestigious title of “Professor of the University of Paris,” much like his son later on. Together with Dr. Resana from Argentina and Dr. Orseni from France, he helped perform the first 100 esophageal operations using colon interposition instead of the small bowel favored by Orseni. ³²

Figure 1. Rene Toupet, father of André Toupet.

Toupet describes his childhood as “easy” and “pleasant.” He attended a very reputable private boarding school, L’Ecole des Roches, in Normandy. Although privileged by wealth, he was by no means spoiled. He credits his father, who fostered a strong work ethic, as being his greatest motivator. In reference to his father, he states, “I owe him everything. He not only taught me surgical technique, but love and respect for the patient, scientific integrity, avoidance of materialism, and the refusal of ‘dichotomies.’” (“Dichotomies” refers to a practice formerly used to reward financially referrals from general practitioners.) Toupet realized that the self-discipline his father taught him was “essential to the professional golfer, the pianist as well as the surgeon.” He remembers taking fly-fishing lessons from his father on the lawn of the property for 6 months before being allowed to go to the river.

Toupet completed high school in 1933 at age 18, earning his baccalaureate degree in philosophy because he disliked mathematics. He considered himself manually inclined and was an avid sportsman, enjoying lawn hockey, swimming, soccer, and competitive rowing. He was known for his chiseled appearance that rivaled that of many body builders. He was also a keen trout fisherman. His greatest passion, however, was discovering more efficient solutions to everyday tasks. From a very early age, Toupet was fascinated by how things worked, often disassembling toys and rebuilding them. To this day, his children and grandchildren refer to him as the “inventor.”

In 1939, just before World War II and on graduation from medical school, he married Henriette Millon, and their family grew to include five children. His wife would later join him in the operating room as his scrub technician for 20 years (Fig. 2).

Figure 2. André Toupet with his wife and children.

Toupet spent the next 6 years in a combined premed/medicine program at the University of Paris. In 1939, at age 24, he was about to graduate from medical school when World War II broke out. He was hastily enrolled in the French army as a doctor and was not sent to the front lines.

He had some difficulty passing the surgical examination to enter a residency: it was a highly competitive test with 80 positions offered to 800 candidates. Five attempts were permitted, and he succeeded on the fourth try, ranking a respectable 30th at the last attempt. He was appointed Intern of the Hospitals of Paris, a prestigious body of surgical house officers. He completed his residency in 1943 after interning under his father for 2 years. Rene Toupet demanded that his son practice his technique repetitively. He was required to perform 50 procedures on cadavers or surgical specimens before attempting his first surgical case. André Toupet would take gastric specimens home and cut and create tissue anastomoses on a towel in his bathroom. He also practiced knot tying on a homemade trainer that consisted of a top hat specially designed to hold sutures. Today, he admits that it was perhaps not wise to have spent the entire 2 years under his father’s apprenticeship. This limited his exposure to other leading surgeons and may have decreased his chances for career advancement. At the time, training under illustrious professors was essential to pursue an academic career and become a “Professor.”

During his residency, Toupet visited the morgue regularly and requested cadavers on which he practiced his surgical techniques. In the large Parisian hospitals, adhering to a well-ingrained ritual, five or six autopsies were conducted every morning. The laboratory technician removed all organs and left them for the chief surgeons, who came accompanied by 10 assistants to discuss the postmortem diagnosis. Once a week, Toupet arranged with the technicians to allow him to work first. He was therefore able to perform six or seven operations. When a technique did not yield good clinical results, he would go to the laboratory in an attempt to improve on it. In this way, he continually strove to refine a technique so as to minimize complications and improve effectiveness. He continued this cadaveric experience throughout his professional career, totaling more than 1,000 dissections in his lifetime.

Toupet was intrigued with every form of abdominal surgery, particularly surgery of the colon and rectum. He was initially not interested in the management of hiatal hernias. At that time, the treatment of GERD relied solely on the correction of the anatomic abnormality: the hiatal hernia. This was accomplished by closure of the esophageal orifice with three tight sutures after retraction of the stomach into the abdomen and reconstruction of the angle of His. This was known as the technique of Lortat-Jacob, named after a leading esophageal surgeon and influential French professor. ^33,34 Lortat held the position of Surgeon in Chief of the largest surgical department in Paris. He was also the president of both the French National Medical Board and the prestigious French Academy of Surgery. ³⁵ He would have a significant impact on Toupet’s professional life.

As an assistant of the renowned surgeon Dr. Jacques Hepp (well-known French liver transplant surgeon Prof. Henri Bismuth also trained under Dr. Hepp), ³⁶ Toupet followed the patients who had undergone the Lortat-Jacob procedure. Some of the patients also had a Nissen fundoplication. He became troubled by the high incidence of postoperative dysphagia that would disappear spontaneously after 10 days or after instrumental dilation. He rationalized that the sutures broke down as a result of the dilation or else the crura separated spontaneously as a result of the constant tension from the tight repair and secondary tissue swelling. While at Bichat Hospital in Paris, Toupet experimented on cadavers in an attempt to find a solution to the problematic dysphagia. He postulated that the mechanical defect leading to hiatal hernias was not related to a widened diaphragmatic hiatus, but rather to the stomach prolapsing into the chest. He believed it was important to correct the prolapse by fixing the stomach to the esophageal crura. He likened this to the treatment of rectal prolapse, in which the problem is not with anal dilation, but with loss of fixation of the rectum. He was convinced that it was the rolling of the stomach that pushed and widened the hiatus. It was therefore mandatory to avoid any crural closure. Instead, he believed that the esophageal hiatus should be buttressed with the stomach fixed to the crura. This would allow the crura to regain their tonicity.

In his opinion, the absence of crural closure during the repair of a hiatal hernia was essential to avoid tension. This was the fundamental landmark of his fundoplication. Moreover, at the time, some of Nissen’s patients were also having postoperative dysphagia problems. This led Toupet to conclude that a full wrap was unnecessary. It is from this experience and his observations from cadaveric dissection that he developed the concept of an antireflux posterior partial valve.

He was encouraged to present his innovative work at the French Academy of Surgery by Dr. Meillere, his professor and friend. However, Toupet had serious reservations based on his limited experience of only four patients. Nonetheless, Toupet presented it to a distinguished audience. This included Dr. Lortat-Jacob, who was one of the most influential surgeons in France and was considered the authority in the field of hiatal hernia repair. ^{33,34,37–39} After Toupet’s 30-minute presentation, Dr. Lortat-Jacob severely criticized him and demeaned his work as “cadaver experimentation.” Toupet was greatly affected at the time but now admits that he stepped into Lortat’s territory poorly prepared, with a small series and short follow-up. In the wisdom of hindsight, Toupet notes that “men, like animals, tend to defend what they consider their private territory.”

The presentation at the French Academy of Surgery, which led to the only publication (March 27, 1963) by Toupet of the posterior fundoplication, ¹¹ is included here in its original complete transcription, translated verbatim:

In the years that we have spent at the surgical clinic of the Hospital Bichat following our mentor, Dr. Hepp, we have become interested in the numerous surgical techniques recommended for the repair of hiatal hernias and achalasia. We have never found any of the techniques to be satisfactory. They have often appeared paradoxical or disappointing. Furthermore, even if the results obtained are sometimes good, in a certain number of cases, these procedures result in failures that are difficult to treat. The resection of the fundus and cardia for peptic ulcer of the esophagus is perhaps an elegant operation, but it would have been more logical to avoid it in the first place by a technique to prevent esophageal reflux. The techniques for the treatment of achalasia or hiatal hernias involve a fine balance between a loose and a tight repair leading to an incompetent wrap or stenosis.

The Heller operation would have been a magnificent procedure if it didn’t predispose to gastroesophageal reflux, sometimes with worse consequences than the disease it aimed to treat. This has led some to prefer dilation to surgery. The suturing of the crura as well as Allison’s operation for the treatment of hiatal hernias are not satisfactory solutions. The suturing of the crura is difficult to calibrate, often followed by intense dysphagia requiring dilations. Therefore, one would ask, “Why are the results good in general?” This is the question that we have often asked ourselves. For a long time, we have thought that the essential step of the operation is the closure of the angle of His combined with the dissection of the abdominal esophagus. This creates an area of adhesion, well known to the surgeon who has to reoperate on these patients. We cannot conceive that the suture of the crura alone, which are often weak, and tear under the “cutting” pressure, can recreate a normal esophageal hiatus. We also cannot imagine how the fixation of the phrenoesophageal membrane in Allison’s procedure can prevent the cardia from migrating into the chest.

As for Heller’s operation, everyone agrees to add an incomplete esophagogastroplasty. This is accomplished by the closure of the angle of His. It is completed by the fixation of the fundus to the peritoneum of the left hemidiaphragm and by the fixation of the same fundus to the left crura.

If the recreation of the angle of His is so important, can we achieve better reflux control and prevent the fundus from migrating into the chest when the esophageal hiatus is enlarged? This is the problem that we have attempted to solve. The solution that we propose today is to create a wrap by fixing the fundus to the posterior aspect of the abdominal esophagus in a “semi-gutter shape” [verbatim translation; meaning 180° posterior wrap] and to complete this esophagogastroplasty by a gastropexy fixing the fundus to the crura of the diaphragm. We can, therefore, hope that the wrap will stop reflux and the fixation will prevent the migration of the stomach into the chest. This technique was inspired by the procedure in which an anastomosis with a wrap is created after total gastrectomy. This was reported in 1956 here at the Academy by our mentor Dr. Meillere. This concept influenced Nissen in developing his procedure of fundoplication. We shall discuss Nissen’s procedure after presenting our technique.

Figure 3. Original posterior fundoplication: suture of the right hemifundus.

Figure 4. Original posterior fundoplication: suture of the left hemifundus.

• Mobilization of the abdominal esophagus
• Mobilization of the posterior aspect of the fundus
• Esophagogastroplasty with phrenogastroplasty.

This is here, we believe, the uniqueness of our technique rejected by Dr. Lortat-Jacob. We will even be much bolder because Dr. Lortat-Jacob has forced us to express our thoughts. We will tell him that the sliding hernia that represents about 90% of all hiatal hernias should be likened more to a prolapse than a hernia. It is absolutely comparable to the genital and rectal prolapses, with a difference being that it involves an intermediate segment of the intestine rather than a terminal segment. Surgeons commonly consider a prolapse as something that descends. But if we can remember that those sliding hernias will mainly manifest themselves in the Trendelenburg position and that the abdominal pressure is not related to gravity, then this comparison between hiatal hernias and prolapse could be justified. In both cases, the attachments are loose and there is no real peritoneal sac, but rather a cul-de-sac that distends with increased abdominal pressure. Therefore, as with a prolapse, we think that the fixation, the obliteration of the cul-de-sac and the irritation of the serosal surfaces are essential, while the suture-closure of the esophageal hiatus is not. It is also possible after this repair for the muscular fibers of the crura to regain their tonicity because they are not stretched anymore by the fundic prolapse as with the anal sphincter and the perineal muscles in the treatment of rectal and genital prolapse.

This is the technique that we would like to propose. We would like to admit that we would never have presented this technique today if a previous discussion by Dr. Hepp following the presentation of Dr. Dor from Marseille on a similar subject had not challenged us.

Finally, even if our cadaveric experience with this procedure is considerable and we can assure you that the realization of this technique is very simple, we are only able to report on four cases with a limited follow-up to justify this technique. We hope that the radiologic documents that we will show you now will convince you.

As for the efficacy of Toupet’s fundoplication, which is a modification of the one proposed by Nissen, I am certain that it is effective as a sagittal view of this procedure indicates the same wrap as the one created by Maillard, Fekete, and myself following esophagogastric anastomosis.

I regret that in his communication, Toupet combines his technique for treatment of hiatal hernias with the identical one performed as an additional procedure following Heller’s myotomy. This is because an evaluation of the results should be done with clinical data regarding the comfort of his patients and especially their ability to separately. I would also like him, despite his great cadaveric experience, to provide us with clinical data regarding the comfort of his patients and especially their ability to belch. Finally, I would like to criticize some of the figures that he has presented in which his artist has left the transverse fibers that should not have been present anatomically if the myotomy of the circular muscle layer was complete.

This presentation at the French Academy was a disaster. The criticism by Lortat-Jacob, reducing Toupet’s experience to a mere cadaveric series, had a profound impact on Toupet and the adoption of his technique in France. Toupet never published the technique again in a scientific journal. Ironically, Toupet only performed a total of 20 hiatal hernia operations in his career.

The left gastric artery was divided to allow a better mobilization of the posterior fundus. Of note, the short gastric vessels were never taken down.

Toupet later added a pyloromyotomy, convinced that pyloric hypertrophy contributed to the pathogenesis of hiatal hernias. The fixation of the posterior fundus to the most superior aspect of the fibrous aortic orifice with the first and lowest suture became an essential step of the gastropexy.

Toupet’s practice was not large but allowed him to live comfortably. His main area of interest remained colorectal surgery, and he described several innovative techniques, including the modification of the Duhamel pull-through procedure that also bears Toupet’s name in France. ⁶

He invented many operating instruments, including a midline retractor still in use in most operating rooms in France. He did not profit from these inventions because he was not interested in financial gain. He was only motivated by the quest for discovery and as such can be considered a true pioneer in his field.

Toupet spent most of his career at St. Cloud Hospital in Paris. He also served as senior consultant at the University of Paris. He never entertained ambitions of becoming a professor because he did not like to give formal lectures. He believed he lacked the presentation skills necessary to deliver serious lessons. He humbly considered himself a “surgeon-technician,” with his laboratory being the cadaveric theater.

Toupet was never invited to the United States, probably because his work was not published here. He felt no resentment about it. Only one of his assistants, Dr. Leroux, translated some of his work into English and tried unsuccessfully to take his innovations to the United States. Toupet’s attempt to publish the technique of “Anterior colorectal intubation with temporary transanal diversion, a new technique for low anterior colorectal anastomosis” was rejected.

Toupet was asked to give a final presentation at the French Academy of surgery. Throughout the years, the Academy had not widely adopted his contributions. Several professors had been irritated by his constant obsession with surgical detail and his desire to improve other surgeons’ techniques, including his father’s. Surgeons may have believed that he was taking their techniques away. His failure to collaborate with others and the paucity of scientific publications made him an easy target for criticism. This criticism was undoubtedly most severe when Toupet presented his hiatal hernia work at a time when the Nissen procedure was being highly touted.

Toupet was also bitter that his father had not received the honors that he might have deserved. In this difficult context, he delivered the following speech on September 1980 at the French Academy of Surgery (verbatim translation):

“It is the last time that I am coming here before retiring on October 1, 1980, after presenting some films at the upcoming annual meeting of the French College of Surgeons.

Gentlemen, the profession of surgery that I have loved passionately has always given me great satisfaction, not the private practice aspect of it, not the honors that I have always refused, but the joy of discovery and innovation. I have had the pleasure of discovering more than 30 surgical techniques, some of which are still unique and will probably remain so.

It is mostly to my cadaveric experience that I owe these accomplishments. I have performed more than 1,000 procedures on the cadaver before proceeding with my first rectal procedure on a patient. I practiced this operation 200 times on a cadaver and performed 50 angiographies to delineate the vascular anatomy. This cadaveric experience has always been essential to me and I am very surprised that great surgeons have not understood its merit and have even criticized me here for this experience. Perhaps it is because this opinion is also shared by the majority of you that there is so little interest of our academy for the cadaveric lab of the “Fer a Moulin.”

It is not merely enough to promote competent colleagues. One has to give them the means to practice their talent. Do you know what the attendance of the surgical residents of the University of Paris to the cadaveric lessons of the “Fer a Moulin” is? 1% to 2%. We have reached a critical point. This has to change. How? By establishing a school of surgery with mandatory teaching sanctioned by a competitive exam to earn a diploma, without which it would be impossible to practice surgery.

This is what my father proposed to you 40 years ago when he was expected to follow Dr. Sebileau at the “Fer a Moulin.” You have not followed his advice and you have allowed Braine to get the job in lieu of Mr. Toupet, Sr. without protesting. Is this how the French Academy should thank the one person that it owes its very existence? I would like to remind you that the transformation of the French Society of Surgery into the French Academy is based on the work of my father, Rene Toupet, and not of Antonin Gosset, as is commonly believed.

I do not want to create more turmoil, as I have much more to say, but I would like to turn myself to the young surgeons that I see at the back of this room to tell them the following: We have been cowards or indifferent, which is no better, or even blind, which would have been more forgivable. It is up to you to proceed with the courage to oppose the residents in surgery and create a new school of surgery. By creating this school, and a qualifying diploma, this will be the only way to fight against second-class surgery. You know what I mean!

I know that this task is very difficult; one would need tremendous courage, as everything is to be done. We are still in the cave and in the dark [reference to Plato’s myth of the cave].

Please forgive me, my dear colleagues, for these tough words. This is maybe due to the friendship and the love that I have for many of you. To the young surgeons here, I say, my friends, good luck and great courage.”

Toupet retired in 1980 at age 65 and completely abandoned the field of surgery (Fig. 5). He never had any contact again with any of his colleagues. Toupet now lives in a high-rise in a better part of Paris surrounded by many beautiful Impressionist paintings by Pissarro (Fig. 6). He lives alone with the biweekly assistance of a maid. When asked what accomplishment he is most proud of in his life, he stated, “being the father of 5 children and grandfather of 14.” His wife died in 1997, just 2 years before our interview, and an emotional Toupet had great difficulty discussing her memory. He denies having any regrets in his life and is thankful for every day he is alive. He has never undergone any surgical procedures and is currently, at age 85, in excellent health. He never missed a single day of work during his 45-year career.

Figure 5. André Toupet at age 65 in 1980, the year of his retirement.

Figure 6. André Toupet at home during the interview, June 1999.

Beyond the description of the partial posterior fundoplication that bears his name, currently performed in conjunction with a Heller myotomy to prevent reflux or for treatment of intractable GERD, we believe that Toupet made another equally important contribution. Specifically, his description of the negative effect of suturing the esophageal crura under tension and the requirement to buttress the hiatus rather than close it to avoid a breakdown of the repair is the other major landmark of his operation. Toupet might have suggested the concept of a “tension-free repair” of the enlarged esophageal hiatus 40 years ago, analogous to the current management of inguinal hernias. Recent studies based on radiologic follow-up have shown that there is about a 40% recurrence rate of paraesophageal hernias after laparoscopic management. This has led some to recommend an open approach through the chest. ⁴¹ In the light of Toupet’s findings, we would suggest that the problem might reside in the tension of the repair rather than the type of approach. Several authors have recently and independently advocated the use of mesh to obliterate the wide hiatal defect encountered in the laparoscopic repair of paraesophageal hernias. ^42–44

Toupet’s life has been a paradox. His name is widely recognized among surgeons worldwide, almost reflexively uttered whenever discussions of surgery for gastroesophageal reflux arise. However, he played out his career in relative solitude, braving criticism in his own country, and remained absent from the raging scientific debates at the height of popularity of surgical treatment of hiatal hernia.

It is a tribute to Toupet that his ideas continue to permeate the international community despite the obstacles he faced. Perhaps his greatest contribution has been his fastidious insistence on the development of innovative surgical techniques, always striving for improvements to benefit his patients as well as students of surgery at all levels.

The authors thank André Toupet for his hospitality and for the permission to reproduce the articles and illustrations shown. Our encounter with this great surgeon was certainly a highlight of our professional life. We are also grateful to Masson Editor (Paris) for permission to translate Toupet’s original article.