Key teaching points:

• internal hernia is an important (and not uncommon) complication of gastric bypass
• right-sided anastomosis is abnormal and indicative of internal hernia
• internal hernia can be complicated by a spectrum of twisting/volvulus, as in this case
• notice the obstruction of both the Roux limb and pancreaticobiliary (afferent) limb leading into the jejunojejunostomy

Operative note (edited excerpt): "We followed the Roux limb towards the JJ. We were unable to follow the bowel since there was a clear twist in the JJ anastomosis and the bowel was not mobile. We identified the terminal ileum and followed the bowel proximally, and we identified an area where we undid a twist in the mesentery and eventually were able to identify the JJ, which was now untwisted. We saw a wide-open jejunojejunostomy mesenteric defect. We followed the common channel distally without issue. We then followed the pancreaticobiliary limb back also without issues. We finally followed the Roux limb back down to the JJ without any residual abnormality. We then closed the jejunojejunostomy mesenteric defect with a running V-lock suture..."