Introduction: Congenital intestinal malrotation presents a unique set of challenges during laparoscopic Roux-en-Y gastric bypass (LRYGBP). As obesity surgery becomes more common in western nations, bariatric surgeons are more likely to encounter patients with intestinal malrotation. Familiarity with alternative operative strategies is necessary for safe laparoscopic intervention when this condition is present.

Methods: We present our experience with 3 malrotation patients in a series of 733 laparoscopic Roux-en-Y gastric bypass operations. All operations were performed by a single surgeon using linear cutting stapler technique. A compilation of findings is presented, including several anatomic variations encountered in intestinal malrotation. The important ramifications of pre-operative vs intraoperative diagnosis are discussed. Topics include port placement, identification of the proximal small intestine, layout of the intestinal limbs, and approaches for constructing the gastrojejunostomy. A brief summary of the surgical literature describing intestinal malrotation in bariatric surgery is provided. Statistical analysis was performed using Vassar online statistical calculators.

Results: The incidence of malrotation in patients undergoing bariatric operations is slightly higher than that commonly cited in the general population, although chi-square analysis reveals that this is not statistically significant. Technical performance of LRYGBP differs for malrotation patients when compared to patients with otherwise normal intestinal anatomy.

Conclusion: Congenital intestinal malrotation will occasionally be encountered in patients presenting for bariatric operations. Malrotation does impact technical details of LRYGBP; however, the presence of this anomaly does not preclude safe performance of LRYGBP, provided the surgeon is familiar with the unique issues associated with this disorder.