Patients with severe GERD resistant to medical therapy are benefited greatly by laparoscopic fundoplication provided that there is careful preoperative patient selection and evaluation. Preoperative evaluation should include contrast esophagography, EGD with biopsies, stationary manometry, and 24-hour pH analysis. Significant esophageal shortening or severe dysplasia are contraindications to laparoscopic fundoplication. A short, loose Nissen fundoplication should be performed in patients with adequate esophageal body function, whereas patients with esophageal dysmotility should be offered a partial fundoplication such as the Toupet procedure. If these guidelines are followed, long-term good results can be expected, with minimal complications, and all of the advantages of the minimally invasive approach.