Background : Patients with choledocholithiasis are usually managed with endoscopic retrograde cholangiopancreatogarphy (ERCP). However, this is not always possible when the patient has very large stone burden or surgically altered anatomy. Major hepatectomy also not always possible when the patient has both side of IHD stones or operational risk is high. In this report, we introduce another treatment method using Endourologic equipment for mentioned situation.

Methods : We report two cases of a patient with complex intrahepatic stones who previously failed several standard endoscopic attempts and was eventually managed by endourologic equipment. Case 1 : A 64 years old woman presented several months history of right upper abdominal pain. Abdominal MRI and CT showed multiple common bile duct stone and both intrahepatic duct stone with diffuse dilatation of biliary tree and atrophy of Lt hepatic lobe. The common bile duct was isolated and Lt hemihepatectomy with choledochotomy was performed. Common bile duct and Lt bile duct stones were removed in the standard manner using forceps. Through the choledochotomy, a flexible ureteroscope was passed into the common duct and Lt bile duct opening. Rt bile duct stones were fragmented using holmium laser fiber with flexible ureteroscope. The larger stone fragments were removed with a basket while the smaller stones were flushed out. Case 2 : A 80 years old woman suffered from recurrent cholangitis due to intrahepatic duct stones. Recurrent cholangitis was caused by right intrahepatic duct stones. Several times of ERCP failed and PTBD was inserted. During operation, the common bile duct was isolated and a flexible ureteroscope was passed into the common bile duct opening. Injection of indigo carmine solution via PTBD, the location of Rt hepatic duct stones were identified and fragmented using holmium laser fiber with flexible ureteroscope.

Results : In both cases. all biliary systems were examined and all subsegmental ducts stones removed in a similar fashion. The procedure was then completed by hepaticoduodenostomy or hepaticojejunostomy. In postoperative periods, One patient has wound infection, other has pneumonia. Both patients discharged after proper treatment.

Conclusions : Using endourologic equipment through choledocholithotomy is another useful method to remove choledocholithiasis, especially in complex cases that failed ERCP or hard to resection. However, long term outcome is uncertain, further follow up examination is needed. In conclusion, this methods should performed to highly selective patients.