Anatomic variation is not uncommon in the surgical world. It often presents challenging situations that provoke the problem solving skills of the surgeon. We present the case of incidentally discovered congenital intestinal malrotation at the time of laparoscopic Roux-En-Y gastric bypass. This is a video representation of successfully performed weight loss surgery with a safe, effective mechanism and no significant increase in operative time.

Once the anatomy has been defined, gastric bypass can be performed with minor changes to the operation. First, a Ladd's Procedure should be performed if necessary with an optional appendectomy. Duodenocolic ligaments, or Ladd's bands, may need to be divided in order to avoid volvulus and obstruction. As the final position of the Roux limb will come to lay directly over the gallbladder fossa, cholecystectomy should also be performed. Finally, a shortened mesentery, often identified in these patients, may necessitate shortening of the Roux limb.

Total operative time was 2 hours, 52 minutes. No clinical abnormalities have been identified in the immediate postoperative period, including a normal upper GI. We look forward to evaluating the patient's progress over the upcoming year.

With adequate knowledge of developmental anatomy, laparoscopic gastric bypass is both feasible and safe in patients with congenital intestinal malrotation. If one chooses to undertake this operation, it is important to remember the salient portions of the case: an optional cholecystectomy, optional appendectomy, lysis of Ladd's bands and shortening of the Roux limb if necessary.