90 year old female with history of CAD, jaundice, and acholic stools. Admission laboratory tests were significant for bilirubin 2.0, SGOT 108, SGPT 110, alkaline phosphatase 699, Ca 125 312, and Ca 19-9 33. CT scan showed dilated intra and extra hepatic bile ducts, cholelithiasis, and ascites. Paracentesis revealed no malignant cells. An ERCP with papillotomy demonstrated two stones within the CBD. The stones were large and could not be removed through the papillotomy. The patient then underwent LC with IOC, and LCBDE. The MIG was deployed through an anterior choledochotomy. The 2.8mm choledochoscope was used to visualize the stone. A 4F irrigation catheter was deployed through one of the smaller MIG lumens, while a 1.7F lithotripter was deployed through the working channel of the choledochoscope. The large impacted stone was easily fractured with the lithotripter, while the debris was flushed away with irrigation, and a clear field of view obtained. Once the stone was fractured and now made smaller, the stone was dislodged with a balloon catheter and removed through the choledochotomy. The entire biliary system was inspected with the choledochoscope. The MIG was repositioned 180 degrees to inspect the proximal bile ducts. The choledochoscope easily passed through the ampulla into the duodenum. The bile duct walls showed marked inflammation. A T-tube was placed, the gall bladder removed, and the operation completed. Operative time 2' 15". Postoperatively the patient had an episode of atrial fibrillation and CHF. She was discharged to a nursing home on postoperative day 7. She continued to improve. A T-tube cholangiogram demonstrated the bile ducts to be free of stones. The T-tube was removed five weeks postoperatively. The patient returned to independent living.