Laparoscopic repair of a free perforation of a marginal ulcer after Roux-en-Y gastric bypass: a safe alternative to open exploration.

Objectives: We present 2 patients with free perforation of the anterior wall of the Roux limb due to marginal ulceration after an antecolic laparoscopic gastric bypass and describe the surgical management and laparoscopic repair technique.

Methods: A 15 mm Hg pneumoperitoneum was established with a Veress needle via the left subcostal approach in both patients. Entrance into the abdomen was achieved with the 5 mm Optiview blunt trocar. The Genzyme liver retractor was used to lift the left lobe of the liver and expose the gastrojejunal anastomosis. A 30 degrees 5 mm telescope was used for visualization. In both cases, free fluid and purulent material were noted in the subdiaphragmatic region and along the right paracolic gutter, but the gastrojejunal anastomoses was intact. A 1 cm perforation with surrounding inflammatory exudate was identified on the anterior surface of the Roux limb distal to the gastrojejunostomy. The edges were debrided and intracorporeal 1-layer repair of the ulcer was performed with simple interrupted 2-0 Vicryl sutures. Fibrin glue was applied to the suture line and covered with an omental onlay patch. The anastomosis was tested with air insufflation and methylene blue dye with no evidence of a leak. A Jackson-Pratt drain was placed in the left upper quadrant.

Results: Both patients underwent an unremarkable hospital course, and follow-up EGD examination after 3 months revealed no evidence of ulceration.

Conclusion: Laparoscopic exploration and the repair of the gastrointestinal perforations in patients with a recent history of laparoscopic RYGBP is safe, if patients are hemodynamically stable and present within the first 24 hours of the onset of symptoms.