Background

Pancreatoduodenectomy is a complex procedure consisting of two main stages: the resection stage with or without pylorus preservation and the reconstruction stage. In a patient with a history of roux en-y gastric bypass (RYGB), selecting specific techniques for reconstruction after the Whipple procedure is a challenging decision and very important in decreasing morbidity and complication. Here we are presenting a 68-year-old. female with h/o open RYGB in 2003 who was found to have a pancreatic head mass obstructing the biliary and pancreatic duct after a long history of pancreatitis and back pain and underwent a successful laparoscopic Whipple procedure.The video illustrates the importance of identifying gastric bypass anatomy early during surgery. It demonstrates the key elements for reconstruction, including gastric remnant resection vs preservation, and considers pancreatic and biliary reconstruction based on the length of the remnant biliopancreatic limb.In our case, the significant inflammation from chronic pancreatitis and the inability to preserve the pylorus were the main reasons to perform remnant gastrectomy and to avoid adding another anastomosisIn addition, the adequate length of the remnant biliopancreatic limb was appropriate to be used for both pancreatojejunostomy and hepaticojejunostomy