Background : De novo choledocholithiasis in patients post Roux-En-Y hepaticojejunostomy (REY HJ) remains a therapeutic challenge as conventional methods like endoscopic retrograde cholangiopancreatography (ERCP) are rendered ineffective due to anatomical alterations. Laparotomy, stone extraction, and HJ revision is the primary procedure in most instances. Alternative approaches are less well described especially approaches via jejunal limb for stone removal performed via a minimally invasive fashion.

Methods : We present a case of a 23-year-old female who previously underwent open common bile duct excision, REY HJ, and cholecystectomy at 2 weeks old for type 1 choledochal cyst. She presented with dyspepsia and cholestatic liver function test (LFT) and was found to have HJ narrowing with large intrahepatic choledocholithiasis extending to 2nd degree ducts. She underwent transhepatic percutaneous biliary drainage with dilatation for initial decompression. A novel laparoscopic approach and use of endoscopic guided laser lithotripsy intraoperatively aided stone fragmentation and extraction, allowing for her surgery to be completed via minimally invasive fashion. After complete ductal clearance, with noted good diameter and flow of bile across the HJ anastomosis, revision of HJ was deemed unnecessary. Postoperative follow-up was also described to evaluate the efficacy and safety of the intervention.

Results : Laser lithotripsy facilitated fragmentation and clearance of bile duct stones. The procedure was completed successfully laparoscopically, with no significant postoperative complications. Follow-up evaluations confirmed sustained stone clearance.

Conclusions : This case report demonstrates the efficacy and safety of a novel approach for exploration and clearance of choledocholithiasis post REY HJ and is a feasible option in well selected cases.