Since the publication by Dragstedt and Owens in 1943 5 showing the effectiveness of vagotomy in the treatment of duodenal ulcer disease, vagotomy has become the cornerstone of the surgical treatment of duodenal ulcers. There has been a constant evolution in the surgical treatment, beginning with truncal vagotomy combined with a gastric drainage procedure and evolving into the highly selective vagotomy. This evolution was halted in the late 1970s with the appearance of the first H 2 receptor antagonists. The introduction of H 2 receptor antagonists into clinical practice resulted in the majority of patients healing their ulcers with aggressive medical management. 17 The addition of omeprazole 2 to H 2 receptor antagonists and the discovery of Helicobacter pylori 8 have virtually eliminated the need for elective ulcer surgery. Because of the success of medical management, the few operations for peptic ulcer disease that are being done are performed on an urgent or emergent basis for acute hemorrhage, perforation, or obstruction. 7 These patients are usually sicker and tend to be older, leading to higher morbidity and mortality than those seen for elective surgery. 18 Highly selective vagotomy has provided a safe and effective procedure for the treatment of peptic ulcer disease. Clinical series report a mortality rate of 0.3% and a recurrence rate of 3% to 30%. 11,13,16,21 This, together with the emergence of minimally invasive surgery, has provided a new approach to the treatment of duodenal ulcer disease. 14 Katkhouda and Mouiel described laparoscopic vagotomy for the treatment of chronic ulcer disease. 14 Significant benefits are realized with minimally invasive surgery. Laparoscopic vagotomy is not only beneficial to patients refractory to medical therapy but can be used as an alternative to life-long pharmacologic therapy. This has revitalized the operative treatment of peptic ulcer disease. This article summarizes the rationale and development of vagotomy for ulcer disease and the role of laparoscopic operations in the treatment of peptic ulcer disease. The traditional open surgical procedures are discussed, and the laparoscopic modifications are reviewed.