Background: Laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS) is an established, effective operation for treatment of obesity, especially in patients with super obesity (BMI>50). The limits of the procedure are the technical demands and operative time which exceed other bariatric procedures.Aim: To define the initial experience with LBPD-DS with regard to operative time and perioperative outcome at a single institution.Methods: Review of a prospectively collected database for all patients undergoing LBPD-DS from 2004 through 2008. Patients were separated into groups: group 1 included the first 25 patients; group 2 included from patients 26 to 50; group 3 from patients 51 to 75; group 4 from patients 76 to 97. RESULTS: For the 97 patients, 64 were female (66%) and the mean age was 45.5 years (range, 22-70). Mean preoperative weight was 167 kg (range, 110-311); mean preoperative BMI was 56.7 kg/m(2) (range, 37-83), with 78 (80%) of the patients being super obese (BMI > or =50 kg/m2). All cases were completed laparoscopically, except for case no. 4, that required conversion to an open procedure due to intraabdominal adhesions. Mean operating room time was 248 minutes (range, 124 - 546), with a mean of 326 minutes in Group 1, 246 minutes in Group 2, 214 minutes in Group 3 and 199 minutes in Group 4. Mean hospitalization time was 3.4 days (range, 2 - 17), 4.36 days in Group 1, 3.4 days in Group 2, and 2.9 days in Groups 3 and 4. Mortality occurred in 1 patient (1%), due to a cardiac arrythmia (patient 19). Perioperative complications occurred in 13 patients (13%). The rate of complications was similar the four groups: it was 16% in groups 1, 2 and 4 and 4% in group 3. However, serious complications were more common in the first cases, including 2 leaks (2%), both of which presented in Group 1 (patient 2 and 19), 1 intraabdominal abscess (1%), prolonged ventilation (1%), acute renal failure (1%), anastomotic ulceration (1%). No complications related to GI bleeding, stomal obstruction, pneumonia, PE or DVT were identified. Conclusion: LBPD-DS is a technically complex procedure, however significant reduction in operative times and complication rates are observed with experience. After an initial 20 procedures, operative times continue to decrease and anastomotic leak rate and mortality were zero.