Background

Small bowel obstruction in patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) has an approximate incidence of 3%. Given the high risk for bowel ischemia and perforation prompt surgical intervention is imperative to reduce the risk of morbidity and mortality. Although the risk of adhesive disease has decreased significantly in the laparoscopic era it is still a common cause of obstruction. We present the case of a 34-year-old female patient who presented with a small bowel obstruction 4 months following a RYGB for obesity. The patient presented with acute onset epigastric pain and dark bloody emesis with focal peritonitis. The patient was evaluated with a CT which was suggestive of a possible closed-loop obstruction of the proximal jejunum. The patient was taken emergently to the operating room for laparoscopic exploration and was found to have an adhesive band causing acute ischemia and gangrene of 90% of the patient's roux limb requiring resection. The area of ischemia spared the proximal 5 to 10 cm of the roux limb as well as the jejunojejunostomy. In order to restore the patient's bypass anatomy, their prior jejunojejunostomy was resected and a new roux limb was recreated and anastomosed to the remaining viable jejunum to facilitate a salvage procedure. We explore the technical aspects and challenges of this patient as well as our operative technique. Given the significant morbidity and mortality of bowel obstructions following RYGB it is imperative that these patients are evaluated promptly with a low threshold for surgical intervention.