This is a 34-year-old woman with a history of a Roux-en-Y gastric bypass for obesity and subsequent cholecystectomy for cholecystitis presenting with recurrent intermittent right upper quadrant pain. An MRI demonstrated a dilated common bile duct with a distal 6mm stone. Because of her altered anatomy, she was taken to the operating room for a surgical-assisted endoscopic retrograde cholangiopancreatography.
We started with a 5 mm trocar in the left midclavicular region two working trocars in the right abdomen. We mobilized the lateral-most portion of the greater curvature. This is particularly important because it would give the endoscopist a straight-shot toward the pylorus. We made a small gastrotomy and placed corner anchor stitches. The anchor stitches were brought out to the skin with a suture passer, triangulating the location of our endoscopy port. We decreased the insufflation pressure to approximate the abdominal wall to the stomach. This technique, in combination with traction on the anchor stitches while advancing the trocar, facilitated successful transgastric port placement. Excessive traction on the anchoring stitches could injure the stomach wall. Because of this non-traditional approach into the stomach and the fact that the patient was not positioned ideally for an ERCP, access to the ampulla is quite challenging for the endoscopist.
After the endoscopy, we performed a small wedge resection of the remnant stomach, removing our gastrotomy site. The patient did well post-operatively and was discharged once her pain was well-controlled and when she was tolerating a diet.