Laparoscopic techniques have facilitated dissection of the esophageal hiatus by providing clearer visualization and access to this region, thus enabling successful antireflux surgery. We have performed laparoscopic antireflux surgery in 283 patients with symptomatic gastroesophageal reflux disease (GERD) refractory to medical management, including 16 patients with large paraesophageal hernias and six patients who had undergone previous antireflux surgery. Eighty-one per cent (n = 230) underwent a laparoscopic Toupet fundoplication procedure, and 37 had a laparoscopic Nissen fundoplication. Of the 16 surgical repairs for paraesophageal hernias, 10 were accomplished with the Nissen procedure. Regardless of the laparoscopic technique, oral feedings were resumed on the first postoperative day and patients were typically discharged within 24 to 48 hours after surgery. All of our patients reported symptomatic improvement following the laparoscopic antireflux operation, with 89 per cent of the patients undergoing the Toupet fundoplication and 79 per cent of those having the Nissen repair rating their postoperative results "excellent." Only one patient had to be converted to an open procedure (< 0.5 per cent). None of the patients in this series died and the complication rate was only 3.5 per cent. Six patients required reoperation (2.1 per cent), including three of whom originally presented with difficult paraesophageal hernias and did not undergo an initial fundoplication procedure. Thus, laparoscopic fundoplication procedures appear to provide sustained symptomatic relief for patients with refractory gastroesophageal reflux disease, with a rapid recovery and a low incidence of complications.