Background

Introduction: This is a video presentation of a 53-years-old male with history of morbid obesity (BMI=50 kg/m2), and several obesity-related comorbidities who underwent preoperative workup and was cleared for a biliopancreatic diversion with duodenal switch (BPDDS) but suffered a duodenal injury intraoperatively. Case: The abdomen was entered with an insufflation needle, pneumoperitoneum was established, and four laparoscopic ports and a liver retractor were placed. Extensive adhesions were noted making the mobilization of the duodenum and the gallbladder very difficult. The greater curvature of the stomach was stapled off after passing down a 50 Fr Bougie to size the sleeve. The gallbladder was then removed after achieving the critical view of safety but during its dissection an enterotomy was identified at the transition of the 1st to 2nd portion of the duodenum. The duodenum was then divided distal to the duodenotomy. The part of the duodenum with the duodenotomy was wedged out with a stapler. The small bowel was measured from the ileocecal valve and at the 300 cm mark it was anastomosed to the duodenum. After the duodenoileostomy was performed the biliary limb was divided and anastomosed to the ileum at the 100 cm mark downstream from the duodenoileostomy. Mesenteric defects were closed. Upper endoscopy revealed even caliber of the gastric sleeve, intact staple line and intact and open duodenoileal anastomosis. Leak test of the duodenoileostomy was negative. Conclusion: Duodenotomy is a feared complication during a BPDDS. Caution should be taken to prevent them especially in reoperative surgical fields.