Abstract Introduction In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction. Methods We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with χ 2, logistic regression, and Kaplan-Meier analysis. Results A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures ( P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods. Conclusions The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.