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Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
D Lipski, D Garcilazo Arismendi, S Targa
Surgical intervention
1 year ago
3103 views
424 likes
0 comments
07:37
Advanced bariatric surgery: reduced port simplified gastric bypass, a reproducible 3-port technique
Minimally invasive surgery is a field of continuous evolution and the advantages of this approach is no longer a matter of debate. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has shown to be the cornerstone in the treatment of morbid obesity and so far all the efforts in this technique have been conducted to demonstrate safety and efficacy. Nowadays, reduced port surgery is regaining momentum as the evolution of minimally invasive surgery.
The purpose is to describe our technique of LRYGB, which mimics all the fundamental aspects of the “simplified gastric bypass” described by A. Cardoso Ramos et al. in a conventional laparoscopic surgical approach (5 ports) while incorporating some innovative technical features to reduce the quantity of ports. Despite the use of only three trocars, there is no problem with exposure or ergonomics, which represent major drawbacks when performing reduced port surgery.

Our technique can be a useful and feasible tool in selected patients in order to minimize parietal trauma and its possible complications, to improve cosmetic results, and to indirectly avoid the need for a second assistant, thereby improving the logistics, team dynamics, and economic aspects of the procedure.

In our experience, this technique is indicated as primary surgery in patients without previous surgery and with a BMI ranging from 35 to 50. Major contraindications are liver steatosis, superobese patients, and potentially revisional surgery. Although based on the experience of the team, we had also to perform revisional surgery mostly from ring vertical gastroplasty.

From January 2015 to June 2017, we analyzed 72 consecutive cases in our institution with a mean initial BMI of 43.12 (range: 30.1-58.7) using this approach, and the mean operative time was 64.77 minutes (range: 30-155, n=72) and excluding revisional cases or cases associated with cholecystectomy (58.72 min, range: 30-104, n=62).

This approach should be performed by highly skilled surgeons experienced with conventional Roux-en-Y gastric bypass and with one of the patients feeling particularly comfortable. We strongly suggest using additional trocars if patient safety is jeopardized.
Laparoscopic gastric bypass with unexpected intestinal malrotation
There are only a few descriptions of laparoscopic Roux-en-Y gastric bypass (LRYGB) in the setting of intestinal malrotation and these are limited to clinical case reports. Intestinal malrotations usually present in the first months of life with symptoms of bowel obstruction. However, in rare cases, it can persist undetected into adulthood when it could be incidentally identified. The anatomical abnormalities which should alert us to this possibility are an absent duodenojejunal angle, the small bowel on the right side of the abdomen, the caecum on the left, and the absence of a transverse colon crossing the abdomen. Identification and adjustment of the surgical technique at the time of laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial to prevent a very distal RYGB or avoid confusion between the Roux limb and the common channel. The construction of the laparoscopic Roux limb can be safely performed with adjustments to the standard technique.
We present the case of a 45-year-old woman with a long history of morbid obesity, hypertension, and hyperlipidemia. The patient had no complaints and presented a normal preoperative evaluation. After a multidisciplinary evaluation, she was elected to undergo a LRYGB. We report an intestinal malrotation discovered at the time of LRYGB, and detail the incidental findings and the technical aspects which require to be incorporated in order to complete the operation safely.
A Laranjeira, S Silva, M Amaro, M Carvalho, J Caravana
Surgical intervention
1 year ago
1929 views
418 likes
0 comments
08:33
Laparoscopic gastric bypass with unexpected intestinal malrotation
There are only a few descriptions of laparoscopic Roux-en-Y gastric bypass (LRYGB) in the setting of intestinal malrotation and these are limited to clinical case reports. Intestinal malrotations usually present in the first months of life with symptoms of bowel obstruction. However, in rare cases, it can persist undetected into adulthood when it could be incidentally identified. The anatomical abnormalities which should alert us to this possibility are an absent duodenojejunal angle, the small bowel on the right side of the abdomen, the caecum on the left, and the absence of a transverse colon crossing the abdomen. Identification and adjustment of the surgical technique at the time of laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial to prevent a very distal RYGB or avoid confusion between the Roux limb and the common channel. The construction of the laparoscopic Roux limb can be safely performed with adjustments to the standard technique.
We present the case of a 45-year-old woman with a long history of morbid obesity, hypertension, and hyperlipidemia. The patient had no complaints and presented a normal preoperative evaluation. After a multidisciplinary evaluation, she was elected to undergo a LRYGB. We report an intestinal malrotation discovered at the time of LRYGB, and detail the incidental findings and the technical aspects which require to be incorporated in order to complete the operation safely.
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
A Duro, F Wright, PJ Castellaro, A Beskow, D Cavadas, J Montagné
Surgical intervention
1 year ago
1043 views
179 likes
0 comments
06:23
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
Laparoscopic Roux-en-Y gastric bypass (RYGB) after failed Nissen
This is the case of a 62-year old female patient with a BMI of 35 and a history of high blood pressure, dyslipidemia, and morbid obesity. She underwent a laparoscopic Nissen surgery 8 years earlier and presented with recurrent GERD symptoms.

A CT-scan, an endoscopy, and a barium swallow showed a hiatal hernia. It was decided to perform a paraesophageal hernia repair as well as a gastric bypass. A laparoscopic surgery was performed.

There were no complications and the patient was discharged on the second postoperative day. An esogastroduodenal contrast examination was performed 1 month after the procedure. It showed the absence of hiatal hernia. The patient was controlled 3 months after surgery and was found asymptomatic with an Excess Weight Loss (EWL) of 42%.
A Duro, V Cano Busnelli, A Beskow, D Cavadas, F Wright, P Saleg, PJ Castellaro
Surgical intervention
1 year ago
2099 views
171 likes
0 comments
06:12
Laparoscopic Roux-en-Y gastric bypass (RYGB) after failed Nissen
This is the case of a 62-year old female patient with a BMI of 35 and a history of high blood pressure, dyslipidemia, and morbid obesity. She underwent a laparoscopic Nissen surgery 8 years earlier and presented with recurrent GERD symptoms.

A CT-scan, an endoscopy, and a barium swallow showed a hiatal hernia. It was decided to perform a paraesophageal hernia repair as well as a gastric bypass. A laparoscopic surgery was performed.

There were no complications and the patient was discharged on the second postoperative day. An esogastroduodenal contrast examination was performed 1 month after the procedure. It showed the absence of hiatal hernia. The patient was controlled 3 months after surgery and was found asymptomatic with an Excess Weight Loss (EWL) of 42%.
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
L Zorrilla-Nunez, P Zorrilla
Surgical intervention
1 year ago
1405 views
219 likes
0 comments
10:05
A stepwise personal technique of RYGB with hand-sewn gastrojejunostomy
With more than 25 years of experience, we have created a unique laparoscopic Roux-en-Y gastric bypass technique with hand-sewn gastrojejunostomy and several additional steps which offer our patients a safe and reliable procedure.
We routinely use 5 bladeless 12mm trocars. The procedure begins with the creation of a 15-20mL gastric pouch with a tilted orientation for the first stapling (not horizontal), and staple lines are oversewn for both gastric pouch and gastric remnant. A blue dye test is always performed at this stage. The second stage of the procedure includes the creation of a 75cm biliopancreatic limb with division of the mesentery and creation of a mechanical jejunojejunostomy with a 100cm alimentary limb, and hand-sewn closure of the enterotomy. Anti-torsion stitches are mandatory at this point. Closure of mesenteric defects (intermesenteric space and Petersen's space) is accomplished with non-absorbable sutures performed in a routine manner. The third and final stage of the procedure involves the creation of the hand-sewn gastrojejunostomy with an interposed limb and 4 layers of absorbable sutures over a 28-30 French bougie.
Closure of all trocar defects is performed in every patient.
Laparoscopic gastric bypass after open vertical banded gastroplasty
This video shows a laparoscopic reintervention after an open vertical banded gastroplasty in a 51-year-old woman presenting with untreatable gastroesophageal reflux disease (GERD). GERD originated from gastric remnant outlet obstruction. For that reason, we decided to perform a laparoscopic Roux-en-Y gastric bypass. First, very intense adhesions of the greater omentum and the stomach to the parietal peritoneum and the left lobe of the liver are dissected. The gastric remnant is dissected in order to transect it proximally to the stenotic, banded segment. A Roux-en-Y gastric bypass with a 50cm alimentary limb using the OrVil™ orogastric tube and the DST Series™ EEA™ 25mm circular stapling device is performed.
P Vorwald, M Posada, G Salcedo, C Lévano Linares, ML Sánchez de Molina, R Restrepo, JR Torres
Surgical intervention
3 years ago
1643 views
36 likes
0 comments
12:54
Laparoscopic gastric bypass after open vertical banded gastroplasty
This video shows a laparoscopic reintervention after an open vertical banded gastroplasty in a 51-year-old woman presenting with untreatable gastroesophageal reflux disease (GERD). GERD originated from gastric remnant outlet obstruction. For that reason, we decided to perform a laparoscopic Roux-en-Y gastric bypass. First, very intense adhesions of the greater omentum and the stomach to the parietal peritoneum and the left lobe of the liver are dissected. The gastric remnant is dissected in order to transect it proximally to the stenotic, banded segment. A Roux-en-Y gastric bypass with a 50cm alimentary limb using the OrVil™ orogastric tube and the DST Series™ EEA™ 25mm circular stapling device is performed.
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
A D'Urso, M Vix, B Dallemagne, HA Mercoli, D Mutter, J Marescaux
Surgical intervention
3 years ago
1687 views
37 likes
0 comments
03:48
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
Laparoscopic Roux-en-Y gastric bypass: live demonstration and technical details
Roux-en-Y gastric bypass (RYGB) has become a common procedure for the management of morbid obesity. However, learning to perform such a procedure may be difficult as it is made up of very technical operative steps in complex cases of overweight patients with a great amount of adipose tissue. In order to prevent complications, an operative strategy should be adopted, allowing for an easy and rapid acquisition of the technique. Each step is perfectly mastered and outlined.
This video demonstrates a laparoscopic Roux-en-Y gastric bypass performed live, showing all the preoperative and operative patient settings. The surgical technique is thoroughly explained.
M Vix, M Nedelcu, HA Mercoli, D Mutter, J Marescaux
Surgical intervention
4 years ago
7225 views
196 likes
0 comments
28:09
Laparoscopic Roux-en-Y gastric bypass: live demonstration and technical details
Roux-en-Y gastric bypass (RYGB) has become a common procedure for the management of morbid obesity. However, learning to perform such a procedure may be difficult as it is made up of very technical operative steps in complex cases of overweight patients with a great amount of adipose tissue. In order to prevent complications, an operative strategy should be adopted, allowing for an easy and rapid acquisition of the technique. Each step is perfectly mastered and outlined.
This video demonstrates a laparoscopic Roux-en-Y gastric bypass performed live, showing all the preoperative and operative patient settings. The surgical technique is thoroughly explained.
Laparoscopic Roux-en-Y gastric bypass after gastric band removal
This video demonstrates the case of a 50-year-old woman with morbid obesity (BMI of 39). She had a gastric banding placed 7 years before, which became ineffective 3 years after the primary surgery, resulting in band removal 2 years ago.
A secondary bariatric surgery was scheduled, with the decision to perform a laparoscopic Roux-en-Y gastric bypass. This video shows the surgical technique, with special emphasis on dissection of the cardia and lesser curvature, where the anatomy is altered as a result of the previous band. An interesting technical point occurs during the creation of the jejunojejunostomy, where a perforation of the biliary loop is accidentally made during the EndoGIATM linear stapler introduction.
M Vix, C Lebares, M Ignat, D Mutter, J Marescaux
Surgical intervention
4 years ago
2150 views
58 likes
0 comments
32:11
Laparoscopic Roux-en-Y gastric bypass after gastric band removal
This video demonstrates the case of a 50-year-old woman with morbid obesity (BMI of 39). She had a gastric banding placed 7 years before, which became ineffective 3 years after the primary surgery, resulting in band removal 2 years ago.
A secondary bariatric surgery was scheduled, with the decision to perform a laparoscopic Roux-en-Y gastric bypass. This video shows the surgical technique, with special emphasis on dissection of the cardia and lesser curvature, where the anatomy is altered as a result of the previous band. An interesting technical point occurs during the creation of the jejunojejunostomy, where a perforation of the biliary loop is accidentally made during the EndoGIATM linear stapler introduction.
Robot-assisted Roux-en-Y gastric bypass after band removal
Patients ask for a new weight loss surgical procedure after gastric band removal due to a lack of efficiency or to complications. Although gastric banding is a reversible procedure, perigastric adhesions located mostly in the upper part of the stomach can make new approaches to this area difficult.
We report the case of a woman who benefited from a gastric banding in 2006. This gastric band was removed in 2010. The patient developed a left subphrenic abscess, which was drained under CT-scan control postoperatively.
Two years after this procedure, the patient wishes to benefit from a new weight loss surgical procedure as she gained 10Kg since her gastric band removal. She has a BMI of 40 and presents with respiratory and rheumatological co-morbidities.
The preoperative work-up was uneventful, and this is particularly true for the esogastroduodenal contrast exam and the gastroscopy.
During the procedure, multiple omental parietal adhesions were found, as well as tight adhesions between the liver, the stomach, and the left crus.
Dissecting the stomach using a conventional approach was made difficult by the presence of these adhesions, and we had to perform an upper pole gastrectomy of the greater curvature in order to clearly identify the gastroesophageal junction’s anatomy. A complete dissection of the left subcardial area is necessary in order to prevent the formation of an excessively large gastric pouch, which could lead to a regain in weight.
This video covers the whole procedure in detail and highlights dissection challenges, which can occur in patients who had their gastric band removed.
The postoperative outcome was uneventful in this woman, with a significant weight loss at one year.
M Vix, D Mutter, J Marescaux
Surgical intervention
4 years ago
1380 views
46 likes
0 comments
25:55
Robot-assisted Roux-en-Y gastric bypass after band removal
Patients ask for a new weight loss surgical procedure after gastric band removal due to a lack of efficiency or to complications. Although gastric banding is a reversible procedure, perigastric adhesions located mostly in the upper part of the stomach can make new approaches to this area difficult.
We report the case of a woman who benefited from a gastric banding in 2006. This gastric band was removed in 2010. The patient developed a left subphrenic abscess, which was drained under CT-scan control postoperatively.
Two years after this procedure, the patient wishes to benefit from a new weight loss surgical procedure as she gained 10Kg since her gastric band removal. She has a BMI of 40 and presents with respiratory and rheumatological co-morbidities.
The preoperative work-up was uneventful, and this is particularly true for the esogastroduodenal contrast exam and the gastroscopy.
During the procedure, multiple omental parietal adhesions were found, as well as tight adhesions between the liver, the stomach, and the left crus.
Dissecting the stomach using a conventional approach was made difficult by the presence of these adhesions, and we had to perform an upper pole gastrectomy of the greater curvature in order to clearly identify the gastroesophageal junction’s anatomy. A complete dissection of the left subcardial area is necessary in order to prevent the formation of an excessively large gastric pouch, which could lead to a regain in weight.
This video covers the whole procedure in detail and highlights dissection challenges, which can occur in patients who had their gastric band removed.
The postoperative outcome was uneventful in this woman, with a significant weight loss at one year.
Laparoscopic redo after failed Roux-en-Y gastric bypass
This video shows a reintervention after laparoscopic bypass in a 44-year-old woman presenting with a history of dysphagia which began shortly after surgery.
First, a dissection between the inferior surface of the left hepatic lobe and the gastrojejunal anastomosis is performed. The gastrojejunal anastomosis is then dissected on its posterior side and a scarry and stenotic anastomosis becomes visible with a chronic fistula to the excluded stomach.
After resection of the “old” anastomosis, a new gastrojejunostomy is performed using the OrVil™ orogastric tube and the DST Series™ EEA™ 25mm circular stapling device.
P Vorwald, M Posada, D Cortés, S Ayora González, E Bernal, C Ferrero
Surgical intervention
4 years ago
909 views
22 likes
0 comments
14:04
Laparoscopic redo after failed Roux-en-Y gastric bypass
This video shows a reintervention after laparoscopic bypass in a 44-year-old woman presenting with a history of dysphagia which began shortly after surgery.
First, a dissection between the inferior surface of the left hepatic lobe and the gastrojejunal anastomosis is performed. The gastrojejunal anastomosis is then dissected on its posterior side and a scarry and stenotic anastomosis becomes visible with a chronic fistula to the excluded stomach.
After resection of the “old” anastomosis, a new gastrojejunostomy is performed using the OrVil™ orogastric tube and the DST Series™ EEA™ 25mm circular stapling device.
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.
D Ntourakis, M Vix, D Mutter, J Marescaux
Surgical intervention
4 years ago
1353 views
28 likes
0 comments
10:13
Perforated gastric pouch ulcer 4 years after gastric bypass surgery: laparoscopic diagnosis and treatment
The frequency of marginal ulcers is reported to range between 0.6% and 16% after laparoscopic Roux-en-Y gastric bypass. Etiologies include gastrogastric fistula, excessively large gastric pouch containing antral mucosa, H pylori infection, non-steroidal anti-inflammatory drugs use, and smoking [1, 2]. We present a rare case of a gastric pouch ulcer perforation occurring 4 years after a laparoscopic gastric bypass.
Bibliographic references:
1. Perforated ulcer at the gastrojejunostomy: laparoscopic repair after Roux-en-Y gastric bypass. Bramkamp M, Muller MK, Wildi S, Clavien PA, Weber M. Obes Surg 2006;16:1545-7.
2. Multimedia article. Laparoscopic repair of a perforated marginal ulcer 2 years after gastric bypass. Chin EH, Hazzan D, Sarpel U, Herron DM. Surg Endosc 2007;21:2110.