Operative approach to intestinal malrotation encountered during laparoscopic gastric bypass

Congenital anomalies of midgut rotation are uncommon with a 0.2-0.5% incidence. Intestinal malrotation (IM) presents a unique challenge in bariatric surgery during laparoscopic gastric bypass (LRYGB), and familiarity with alternatives allows for safe laparoscopic intervention. IM was encountered in 5 of 1183 (0.4%) patients undergoing surgery. Once IM was suspected, a standardized approach was applied: rightward shift of ports, confirmation of IM by the absence of the ligament of Treitz, identification of the duodenojejunal junction, lysis of Ladd's bands, mirror-image construction of the Roux limb and construction of the gastrojejunal anastomosis. Forty percent were male, age 33 ± 8 years, with body mass index 50 kg/m² (37-75 kg/m²). IM was identified preoperatively in two patients (40%). All operations were completed laparoscopically. Despite the finding of IM, successful laparoscopic completion of gastric bypass can be anticipated if the surgeon has an understanding of the anatomic alterations and a strategy for intraoperative management.