Iatrogenic gastric sleeve perforation following attempted endoscopic dilation is a challenging problem with significant associated potential morbidity. We present the case of a 22 year-old woman who underwent laparoscopic sleeve gastrectomy in Mexico complicated by leak and intraabdominal sepsis with stricture at the incisura. During attempted endoscopic dilation of her persistent stricture 3 months later, she sustained an iatrogenic gastric perforation managed with emergent laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction. Acute resection with reconstruction is a safe and valid option in such patients with iatrogenic perforation and unrepairable anatomy. We recommend discussion of similar cases prior to attempted dilation at a multidisciplinary conference to optimize staff and patient preparedness.