The treatment of achalasia with laparoscopic Heller myotomy and partial fundoplication has become the predominant primary therapy over the last 15 years. A recent randomized trial demonstrating equivalence of balloon dilation and Heller myotomy is unlikely to change our approach, as the balloon dilation strategy required intensive surveillance and frequent retreatment, as compared to laparoscopic Heller myotomy.19 The only real “debate” in this field has been whether to fashion an anterior (Dor) or posterior (Toupet) fundoplication after dividing the LES. A recent randomized trial, closed due to lack of accrual, shows a slight, but not significant, advantage in diminished post-op reflux with the posterior fundoplication.20 Nonetheless, worldwide, the anterior fundoplication is preferred as it requires less posterior dissection and it does not angle the GE junction anteriorly as the posterior fundoplication may do. The only “trap” of the Heller myotomy is carrying the myotomy too far above the diaphragm and inadequately on the stomach. If there is any esophageal outflow obstruction (from reflux stricture, angulation, or incomplete myotomy), the supradiaphragmatic myotomy site, lacking muscular support, may create an epiphrenic diverticulum, a result of the pressurized esophagus. Intraoperative endoscopy, immediately after the creation of the myotomy will identify easily if the myotomy extends to the dilated esophagus and onto the proximal stomach. A completely divided LES will open with air insufflations such that the endoscope “perched” in the distal esophagus can visualize the stomach through the previously spastic high-pressure zone, which will still appear as a waist.