Background

This video illustrates the intraoperative decision-making and technical aspects of performing one anastomosis gastric bypass (OAGB) as a revisional procedure for patients with a history of gastric band erosion.Patient is a 49 year-old female suffering from morbid obesity (BMI 54). She has a history of gastric band erosion, and prior attempted revisional sleeve gastrectomy which was aborted secondary to iatrogenic gastric perforation.Following preoperative endoscopic confirmation of healed gastric mucosa, she was scheduled for Roux-en-Y gastric bypass. However upon entering her abdomen, hostile small bowel adhesions were encountered around what was discovered to be retained gastric band tubing. After extensive interloop adhesiolysis and examination of small bowel, we decided that a small bowel anastomosis for jejunojejunostomy for conventional gastric bypass would add significant risk considering the elective nature of this procedure. Therefore, the decision was made to change the plan towards OAGB, avoiding small bowel anastomosis.A gastric pouch was meticulously created taking into account the dense adhesions in the region of prior iatrogenic gastric perforation and previous band erosion. In this case, using the endoscope as a bougie gave the advantage of guiding the pouch creation under direct vision. The procedure was completed with 150cm biliopancreatic limb and end-to-side gastrojejunostomy with Petersen's defect closure. Patient was discharged next day and has lost 38lbs at 6 weeks without complications.The video underscores dealing with hostile abdomen with retained tubing and prior band erosion. We also illustrate the advantage of intraoperative endoscopy in guiding decision making in such complex revisions.