Standard approach for a Roux-n-Y Gastric bypass (RYGB) cannot be used in cases of intestinal malrotation (IM) as it can lead to twisting of the mesentery. Very few cases have been reported in the literature on how to approach such a case with the use of a robot, especially in relation to port placement and the creation of the jejuno-jejunostomy (JJ).


To present our experience with IM discovered intra-operatively during robotic-assisted RYGB.Case-report40-year-old female with a BMI of 37.6 who was planned for a RYGB due to history of GERD. Pre-operative upper GI series did not report IM. Intraoperatively, the ligament of Treitz was not found at its usual location. The jejunum was then followed retrograde and the ligament of Treitz was identified to the right of midline, denoting a Type 2 IM. From here, the procedure continued in mirror-image fashion to the standard RYGB procedure. The BP-limb was kept on the right side of the abdomen, and the Roux-limb on the left. This allowed the procedure to be completed using the standard port placement. The mesenteric defects which were also flipped were identified closed at the end of the case.


There were no peri-operative complications. The patient is doing well at 1-month follow-up with an excess BMI loss of 40%.


Delayed films in upper GI series can help diagnose IM. Additionally, RYGB in Type 2 malrotation patients can be performed with standard robotic port placement by mirroring the position of the JJ anastomosis