Marginal ulceration after Roux-en-Y gastric bypass for morbid obesity has a variable incidence as reported in the literature. However, it is generally thought that the incidence range is 1.5% to 7%. Use of non-steroidal anti-inflammatory drugs (NSAIDs) as well as steroids increases the risk of this complication. We present our technique for laparoscopic repair of a perforated marginal ulcer using endoscopic assistance.

The patient is a 51 year-old woman who under went Roux-en-Y gastric bypass laparoscopically 3 years ago. One year ago she underwent laparoscopic exploration and repair of an internal hernia. She has a history of marginal ulcer in the past, has been on steroids, and uses NSAIDs frequently. She presented to the emergency department with acute abdominal pain was diagnosed with abdominal free air and small bowel ileus.

The operation is begun by placing 6 ports in the upper abdomen. The Roux limb is in a retrocolic retrogastric position and is identified and mobilized gently with blunt dissection. A collection of purulent and bile-stained (likely due to ileus) material is present between the Roux limb and the gastric remnant. A gastro-gastric fistula, which must be ruled out in this setting, is not present. A combination of blunt and hydro-dissection is used to identify the site of perforation. Dissection posterior to the Roux limb with careful preservation of the mesenteric blood supply allows placement of a bowel clamp.

Once the bowel clamp is placed upper endoscopy is performed. Using a Maryland dissector, a large bundle of non-absorbable suture material is grasped through the perforation and removed using a combination of laparoscopic and endoscopic visualization. The suture is grasped, exteriorized, cut, and removed.

Closure of the perforation is performed using an omental patch technique utilizing intra-corporeal suturing and tying. Care is taken to avoid tearing the tissues. Once completed, the repair is reinforced with fibrin glue, which serves to 1) augment the sealing properties of the omentum, and 2) perform an anti-adhesive function with respect to the liver in case re-operation is needed.

An upper GI study was performed on the second post-operative day, at which time a clear liquid diet was begun. The patient was discharged on the fourth post-operative day.

This video addresses the appearance of a perforated marginal ulcer after Roux-en-Y gastric bypass and demonstrates a feasible technique for repair that uses concurrent laparoscopic and endoscopic visualization.