currently for super - obese individuals , bariatric surgery is the only evidence - based approach that results in clinically significant and sustainable weight loss . with the increasing prevalence of obesity , there is an increased demand for bariatric surgery . subsequently , a large number of patients shall be presenting with the complications of bariatric surgery . a 42-year - old caucasian female underwent laparoscopic roux - en - y gastric bypass in february 2007 . she subsequently developed gallstones , a known complication of bariatric surgery due to rapid weight loss . she presented to our unit in february 2012 with a week long history of right upper quadrant pain associated with vomiting . blood tests revealed deranged liver function tests : alkaline phosphatase of 169 u / l and alanine aminotransaminase of 188 u / l . a computed tomographic scan was organized confirming the appearances of a dilated common bile duct and the potential of a calcified stone in the common bile duct . she was managed conservatively with analgesia and ursodeoxycholic acid to attempt to dissolve the stones . her liver function tests and pain improved , and she was discharged with an outpatient magnetic resonance cholangiopancreatography ( mrcp ) . in march 2012 , her mrcp showed a dilated common bile duct of 10 mm and two small filling defects suggestive of gallstones . again , this confirmed the dilated common bile duct , but also showed free drainage of bile into the duodenum and no gallstones ; hence , therapeutic interventions were not undertaken . she was referred to the gastroenterologists for further advice , but as of june 2012 she was still symptomatic . ultimately , an endoscopic retrograde cholangiopancreatography ( ercp ) and sphincterotomy was deemed to be necessary to alleviate her symptoms . owing to the altered anatomy post roux - en - y gastric bypass , this was to be a technical challenge . the bypass of the distal stomach and proximal small bowel is achieved by anastomosis of the gastric pouch and the jejunum known as the roux alimentary limb . the biliary pancreatic limb is then anastomosed to a small bowel . as a result it is technically challenging to perform an ercp in the conventional manner , two subsequent port sites were used : a 5-mm port site in the right upper quadrant and a 10-mm port in the left hypochondrium ( fig .  1 ) . stay sutures were placed in a diamond - shaped configuration around the gastrotomy site  these can allow both traction and counter - traction . a sterile ercp scope inserted manually through a left 10-mm port site all under laparoscopic visualization . there were no obvious gallstones in our patient ( fig .  2 ) . the gastrotomy site was closed with a two layer closure : the first layer as a running stitch and then as a horizontal mattress with 2.0 vicryl . she was admitted for an overnight stay and discharged the following day . upon review of the patient in a routine 6-week follow - up clinic , she was asymptomatic and was discharged back to the care of her general practitioner . with the increased demand for bariatric surgery worldwide , there will be an increased role of endoscopy to diagnose and manage complications . with altered anatomy , the transgastric approach can be used as an access point into the gastrointestinal tract . we have demonstrated that the technique when performed correctly can be a safe and viable option in most district general hospitals , which would certainly have a laparoscopic surgeon and a gastroenterologist on site .