In severe gastroesophageal reflux disease fundoplication is a sound therapeutic alternative if long-term treatment with proton pump inhibitors is not a viable option. However, careful patient selection is mandatory and reflux disease has to be proven objectively. Patients who are particularly prone to develop postoperative functional side effects should be excluded.For surgical treatment either a 360° wrap (Nissen) or a 270° wrap (Toupet) can be performed with more or less equivalent results. The common technical denominators are to achieve a loose, short wrap. In both instances the cuff has to be fixed securely with non-absorbable sutures and any damage to the vagal innervation has to be avoided.Long-term reflux prevention is excellent and superior to medical treatment; nonetheless, functional side effects still occur and to keep the incidence as low as possible preoperative selection of patients is essential.