Laparoscopic Roux-en-Y gastric bypass (LRYGB) is quickly replacing open techniques in the morbidly obese patient who presents for surgical treatment. Safety concerns about the laparoscopic technique have arisen in the literature with gastrojejunostomy (GH) leak rates of 5% or greater reported in several series. 251 consecutive LRYGB operations were performed between August 2001 to January 2004 by a single surgeon with over 6 years experience. A double layer technique was used for every GJ anastomosis. This consisted of end to side stapled anastomosis using only 30mm of a 45mm blue (3.5mm) staple cartridge that was fired inside the gastric pouch and Roux limb. A posterior running suture was then used to reinforce the back wall. An intra-luminal 32 French bougie was placed before the stapler opening was closed. Finally, 2 running sutures are used to reinforce the anterior and lateral sides of anastomosis. The average patient age was 43 years old (range 18-67), 89% were female, an average preoperative weight of 302 lbs. (range 197-472) and average BMI of 49 kg/m2 (range 35-75). 142 cases were performed with the Ethicon endoscopic linear staplers and 109 with the US Surgical endoscopic linear staplers. There were no anastomotic leaks, staple line leaks, pulmonary emboli, nor in-hospital deaths recorded. One patient died at home one week after surgery. An autopsy revealed no infections, leaks, peritonitis, pulmonary emboli nor myocardial infarction, and therefore the cause of death was deemed arrhythmia by the county coroner. Endoscopic dilation successfully treated 10 (4%) stomal stenosis. Eleven (4%) patients developed marginal ulcers that were easily treated with a proton pump inhibitor. Average excess weight loss at 12 months and 18 months was 63% & 71%, respectively. Laparoscopic results are as good or better than open surgery in the morbidly obese patient. The learning curve for this operation is steep and may reflect the higher leak rates reported by others in earlier series. However, the technique used to create the GJ anastomosis may also account for a lower leak rate. The two layer GJ anastomotic technique shown in the video presentation combines, an inner stapled later and outer sutured layer that yields excellent results.