This is a 54 year old morbidly obese (BMI 44) woman with hypertension, hyperlipidemia and diabetes type II. she is in complete remission of non-Hodgkin's lymphoma and prolactinoma since 1999. She also had biliary colic and gastro-esophageal reflux disease and joint pain. An incidental left adrenal tumor was found on CAT scan for lymphoma follow up. This tumor had increased in size from 2 to 3 cm, and did not reveal any secretion. A Roux-en-Y gastric bypass, ultrasonography, supra-gastric left adrenalectomy and cholecystectomy with intraoperative cholangiogram was performed by the laparoscopic approach. The procedure started with transection of the stomach to create a small gastric pouch. Next, using intraoperative ultrasonography, the left adrenal tumor was located, and a supra-gastric approach was used to perform the adrenalectomy. Subsequently a gastro-jejunostomy, entero-enterostomy, closure of mesenteric defects and cholecystectomy with intraoperative cholangiogram were performed. Estimated blood loss was approximately 200 mL. and operative time was 240 minutes. Pathology revealed an adrenal cortical adenoma of 3.2 cm, and chronic cholecystitis with cholelithiasis. Her post-operative course was uneventful, she tolerated a diet after 36 hours and was discharged 72 hours after the procedure. After 3 months of follow up, she reduced her BMI to 32.79 with no late complications. finally, we conclude that the supragastric approach should be considered when planning a simultaneous laparoscopic gastric bypass and left adrenalectomy.