The dissection of the gastroesophageal junction should be the same, regardless of what kind of final fundoplication or partial fundoplication technique is used. The popularity for one or the other fundoplication depends often on the surgical school or country. For example, the Toupet partial fundoplication is very popular in French speaking countries. The most popular partial fundoplication in open operation is the Belsey Mark IV repair which is, in the original version, always performed through a left thoracotomy. Only very few authors have performed so far a thoracoscopic Belsey Mark IV repair. Other partial fundoplica­tion techniques have all been performed laparoscopically in the past few years.

Despite calibration with a 60F bougie, laparoscopic fundoplica­tion may result in a fundoplication that is tighter than that con­structed during an open procedure. One of the reasons may be the manner in which the wrap is constructed. Ideally, the ante­rior and posterior fundic wall should be folded around the distal esophagus to meet in the right lateral aspect of the esophagus rather than at the anterior or 12 o’clock position. Rudolph Nis­sen described this as a “Witzel” of the distal esophagus into the stomach. This can be difficult to achieve laparoscopically unless attention is given to complete fundic mobilization and the care­ful grasping of the posterior fundus to pass behind the esophagus. This is best accomplished by placing a Babcock clamp through the lower left port (surgeon’s right) and grasping a suitable portion of the posterior fundus. It is then passed be­hind the esophagus from left to right and grasped with the sur­geon’s left hand. We prefer this approach to the more common method of passing an instrument from right to left, as it assures passage of the posterior fundus and not the anterior one, during creation of the fundoplication. The anterior wall of the fundus is then folded over the esophagus above the gastroesophageal fat pad. Both posterior and anterior fundic lips are manipulated to allow the fundus to envelope the esophagus without twisting. With adequate dissection the right portion of the fundoplica­tion should rest comfortably in place without the tendency to retract back toward the spleen. A 60F bougie is then carefully passed under direct vision to properly size the fundoplication. The relative roles of medical versus surgical therapy for gastro­esophageal reflux disease are changing, as both patients and their physicians recognize that surgery provides the only known means of altering the natural history of the disease. At present, it seems that laparoscopic Nissen fundoplication will become the standard of care in the surgical treatment of patients with gastroesophageal reflux disease. Although laparo­scopic fundoplication results in control of typical symptoms in over 90% of patients, it should be recognized that achieving op­timal results requires careful patient selection and attention to meticulous technique. The lessons of history have allowed im­provements in antireflux surgery to the point that excellent re­sults can be achieved in the majority of patients. It is hoped that in this era of minimally invasive surgery, mistakes of the past will not be repeated by those who are unfamiliar with the pathophysiology of the disease or the history of antireflux surgery.