Casajoana A, et al. - Via a 49-year-old female weighing 154 kg with sleep apnea disease who underwent a laparoscopic Roux en Y Gastric Bypass in 2009, researchers demonstrated the technique that was adapted to make the complex case reproducible reducing the operative risk, through a video. A subcostal camera trocar with Optiview was introduced and epiploic adherences to the former anastomosis were noted. An extra trocar was placed in order to eliminate adhesions in the re-operative field. The 300 cm of the small bowel proximal to the ileocecal valve was measured. The antecolic Roux limb from the gastric remnant was divided saving the left gastric artery and the pouch proximal to the gastrojejunal anastomosis was also divided. The remnant stomach saving the 8 lowest branches of the right gastroepiploic artery was recognized and mobilized. Subsequent to reaching the angle of His, the remnant and the pouch could be separated. Using a 42Fr bougie for guidance, the pouch was reshaped. A gastrostomy was created and a matching opening was made near the lesser curvature on the remnant. Gastrogastric anastomosis was initiated. First, the posterior layer was performed and then the bougie was placed through into the remnant. The sleeve and fundic resection was performed. The bougie was replaced by an oral gastric tube and the anterior layer of the anastomosis accomplished. This was tested with the help of methylene blue. The duodenum postpylorus was divided, saving the right gastric artery. A hand-sewn duodeno-ileal anastomosis with a common limb length of 300 cm was done and tested. Intra- or postoperative complications were not noticed and the patient was discharged following 2 days. Hence, a reproducible technique for this complex anastomosis was demonstrated through the video. Preservation of the distal epiploics makes the gastro-gastric anastomosis safer but need direct dissection of the duodenum.