54 year old female s/p laparoscopic-RYGB several years ago presented with epigastric pain and jaundice. CT-scan revealed choledocholithiasis and mild pancreatitis. Preoperative ERCP was not possible given her surgical history. She did not have cholangitis.

Intraoperative cholangiogram revealed markedly dilated CBD and an impacted stone distally at the ampulla. Laparoscopic transcystic choledochoscopy and choledochotomy were unsuccessful; transduodenal sphincteroplasty was required for stone extraction.

Another trocar was placed in the right flank. After kocherizing the duodenum, longitudinal duodenotomy was performed opposite the ampulla of Vater. Sphincterotomy at 10:00 was performed with the ultrasonic scalpel. The impacted stone was removed with a 5Fr Fogarty catheter. Sphincteroplasty was performed with interrupted 5-0 Maxon sutures. The duodenum was closed transversely in two layers. The choledochotomy was closed primarily and the cholecystectomy was completed.

Completion cholangiogram revealed free flow of contrast into the small intestine. The patient was discharged home uneventfully on POD#4.

The RYGB patient with choledocholithiasis poses a therapeutic challenge. Transduodenal sphincteroplasty must be part of the surgeon's armamentarium, as this is occasionally required for impacted stones. This procedure can be safely done laparoscopically.