We propose that selective fundoplication during laparoscopic Heller myotomy achieves optimal outcomes. Fundoplication was applied selectively in 21 of 100 patients undergoing laparoscopic Heller myotomy with hiatus hernia, patulous esophageal hiatus, or intraoperative perforation. Dysphagia and heartburn incidence and severity in patients undergoing myotomy with or without fundoplication were compared before and after myotomy. Median follow-up was 19 months and was similar for both groups. Preoperative symptoms were similar for both groups of patients and showed significant improvement following myotomy with or without fundoplication. As well, there were no significant differences in postoperative dysphagia (26% vs. 14%), dysphagia score (1.1 +/- 1.4 vs. 0.8 +/- 1.3), heartburn (21% vs. 27%), or heartburn score (0.9 +/- 1.5 vs. 1.4 +/- 1.6). Overall improvement was seen in 86% of patients undergoing myotomy with fundoplication and in 97% without fundoplication (P = 0.06). Selective application of fundoplication during laparoscopic Heller myotomy promotes optimal outcomes.