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Background: Nissen fundoplication (NF) is comprised of two components: the fundal wrap which is generally thought to be responsible for the majority of lower esophageal sphincter (LES) function and crural closure which is primarily performed to prevent herniation or migration. The degree to which each of these components contributes to restoration of the LES is unknown. We aim to determine and quantify the relative contributions of each of the components of a NF to the length and pressure of the LES. Methods: Patients with symptomatic GERD with or without a hiatal hernia (< 5 cm) undergoing elective laparoscopic NF were prospectively enrolled in an IRB approved study. All patients underwent preoperative 48 hr pH testing, high resolution manometry and upper endoscopy. Patients with hiatal hernia also underwent barium swallow. Patients were intra-operatively randomized to undergo crural closure followed by construction of the fundal wrap (Group 1) or to construction of the fundal wrap followed by crural closure (Group 2). Intraoperative manometric data including lower esophageal sphincter length and pressure were collected using high-resolution manometry (Sierra Scientific Instruments, Los Angeles, CA). These parameters were recorded after complete dissection of the hiatus and after each of the individual components. Results: Between May and October 2009, 18 patients were enrolled and randomized. There was no difference between the groups in terms of demographics, size of the hernia, severity of GERD or presence of Barrett’s esophagus. Overall, mean LES length was significantly increased by 1.3 cm (p< 0.001) and mean LES pressure was significantly increased by 13.7 mmHg (p<0.001) when compared to completed dissection of the hiatus. No significant difference in end LES length or end LES pressure was found between group 1 and group 2 (p = 0.7 and p = 0.9 respectively). The crural closure and the fundal wrap each make equivalent contributions to the overall change in LES length (p > 0.7). Although there is a trend toward a greater contribution by hiatal closure versus the fundal wrap on LES pressure, the difference is not significant (P=0.07) Conclusion: The aim of anti-reflux surgery is to restore the function of the LES. This is accomplished by increasing both LES length and pressure. In attempting to achieve these objectives, the laparoscopic Nissen fundoplication relies on two main components: the crural closure and the construction of a 360 degree fundal wrap. We have demonstrated that each of these components is equally important in establishing both increased LES length as well as increased LES pressure.