Robert J Conrad, MD, Nicole R Laferriere, MD, Miriam L Brazer, MD, Dylan M Russell, MD, Chan W Park, MD, FACS, Robert B Lim, MD, FACS. Tripler Army Medical Center
Introduction: We present a case in which we performed a laparoscopic sleeve gastrectomy and cholecystectomy, in a patient with intestinal malrotation and a common bile duct anterior to the stomach. The patient is a 51 year old female with class I obesity and metabolic syndrome who presented to our clinic interested in a Roux-En-Y Gastric Bypass (RNYGB), with the caveat that she had congenital anomalies that caused a previous attempt at a RNYGB to be aborted at another facility. She was noted to have malrotation but there was no description of the intraoperative anatomical findings. Preoperative imaging demonstrated intestinal malrotation with the small bowel largely to the right of the abdomen and the large bowel on the left side of the abdomen as well as polysplenia. Also noted is a bilobed liver and an anterior and midline gallbladder with cholelithiasis. Last and most importantly, the portal vein, superior mesenteric vein and common bile duct were anterior to the stomach near the level of the pylorus. Our plan was to offer this patient a RNYGB pending diagnostic laparoscopy and intraoperative real time endoscopy to assess her anatomy. She was also consented for possible Ladd’s Procedure, possible Laparoscopic Sleeve Gastrectomy and Cholecystectomy.
Methods: This is a video case report with intraoperative video narration of a laparoscopic surgery.
Results: In summary, the patient had malrotation with the duodenum extending intraperitoneally to the LUQ but returning retroperitoneally to the RUQ with the common bile duct laying anterior to the stomach. The celiac axis was underdeveloped thus necessitating a laparoscopic sleeve gastrectomy as opposed to a gastric bypass.
Conclusion: The learning point being that, the use of preoperative imaging and intraoperative adjuncts such as diagnostic laparoscopy and endoscopy helped define this unique and complex anatomy, thus allowing for a safe and successful surgical procedure.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95547
Program Number: V212
Presentation Session: Video Loop Day 1
Presentation Type: VideoLoop