Surgical treatment of gastroesophageal reflux disease was described 50 years ago. Laparoscopic anti-reflux procedures were introduced 20 years ago. Over the years a better understanding of the disease and of the indication for surgery lead to the definition of precise surgical steps and principles allowing, when applied, excellent outcome in the majority of patients. These principles are: objective confirmation of pathologic GERD, precise assessment of the anti-reflux barrier, careful patients’ selection, and good surgical technique. In order to achieve good clinical results surgeons should master not only the technical surgical steps but should also be familiar with the pathophysiology of the disease.

Laparoscopic fundoplication together with hiatoplasty is the technique of choice. Different types of fundoplication have been described (360°-270°-180°, anterior-posterior). Laparoscopic Nissen fundoplication is the most widely used type of fundoplication being superior to lesser degrees of fundoplication (270°-180°) in terms of acid exposure control and long term results. In addition laparoscopic Nissen fundoplication is better than optimal medical treatment in controlling regurgitation, although side effects are more common. Partial fundoplication is the technique of choice in patients with very poor esophageal motility and may be associated with less troublesome side effects.