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The clinical features of achalasia and the availability alternative therapeutic options make a patient-tailored approach necessary. Minimally invasive techniques have modified the management of this disease. For patients who meet the diagnostic criteria for achalasia and are suitable for surgery, laparoscopy surgery has established as the first line of therapy; in fact, it is capable to achieve the best long-term clinical and functional results. The Heller-Dor operation should be considered the procedure of choice, even if several technical details are still debated. Adequate exposure, rigorous technique and the use of intraoperative endoscopy or manometry are essential for a safe and effective procedure. Surgical myotomy can also be successfully performed after failed endoscopic therapy; more difficult dissection and higher complication rate may occur in patients who have undergone previous endoscopic therapy, thus strengthening the indication for surgery as a primary treatment. An open approach is rarely performed as the initial therapy and it can be taken into account for patients who have undergone multiple prior abdominal operations or endoscopic procedures or who cannot tolerate a pneumoperitoneum because of cardiac or pulmonary disease.