Minimally invasive choledochotomy and lithotripsy surgery was first introduced and applied in clinical practice (1996), and hundreds of patients have benefited from it. Especially in recent years, combined with laparoscopic technology, the surgical trauma of gallstone patients has been greatly reduced, and patients with gallbladder stones combined with bile duct stones can be discharged within 3 days after surgery, just like patients with simple gallbladder stones. Compared with duodenoscopic papillary sphincterotomy for stone extraction, it eliminates the pain of 2 surgeries (after EST stone extraction, LC surgery), and there are no complications of papillotomy such as pancreatitis and reflux cholangitis. We have also published more than 10 papers summarizing our experience in related journals in China, hoping to promote this technique and benefit the majority of gallstone patients. The traditional biliary exploration requires a T-tube to be left in place after the exploration to prevent bile leakage and biliary stricture, as well as to facilitate the management of residual stones after the operation. However, with the advancement of surgical techniques and instruments, as well as the popularity of minimally invasive concepts, the residual stones of extrahepatic bile duct stones have become nearly zero in the choledochoscopic era, and the pain caused by the tube to the patient and its complications have gradually become the focus of this procedure. In order to solve this problem, our hospital has been performing biliary exploration via microincisional access to the confluence of the bile duct in 72 patients with indications since December 1996 with the assistance of fiberoptic choledochoscopy, and obtained good results. 1. Data and methods (1) General clinical data: 72 cases, including 23 males and 49 females, aged between 26 and 82 years, with a median age of 54 years. (2) Methods Equipment: conventional open lithotripter with various curvatures, OLYMPUS P20 fiberoptic choledochoscope with attached lithotripter basket, biopsy forceps, balloon dilator, and OLYMPUS liquid electrolysis apparatus After conventional resection of the gallbladder, the cystic duct was left about 10 mm, and the anterior wall of the cystic duct was incised to its confluence. A 4/0 absorbable suture is applied at the tip of the incision to prevent the incision from tearing during exploration and stone extraction. The enlarged “choledochal opening” is then passed into the choledochoscope or other instruments for biliary exploration. After exploration, 4/0 absorbable sutures are placed intermittently or continuously to close the common bile duct and cystic duct incision margin completely. The common bile duct is ligated and sutured approximately 3-5 mm from the common bile duct. A drainage tube was routinely placed in Winslow’s orifice. The number of stones ranged from 1 to 5, and the diameter ranged from 0.2 to 1.2 cm. All 53 cases were confirmed to be completely removed by intraoperative choledochoscopy, and 5 cases were treated with liquid electrolysis; 19 cases were negatively explored. The average time for choledochoscopic-assisted stone extraction or examination was 5-20 minutes, with an average time of 8 minutes. Postoperative abdominal drainage tube removal time was 36h-9d, with an average of 48h, and small bile leak occurred in 2 cases. The postoperative hospital stay ranged from 7-14 days, with an average of 9 days. 62 cases were followed up for 2 months-24 months, with an average of 12 months, all of which were confirmed by ultrasound or CT examination, with no biliary strictures and no stone residues. 3. (1) suture of bile duct has the risk of biliary fistula and biliary stricture, and the removal of T-tube is mostly more than two weeks after surgery, the loss of bile, water, electrolyte metabolism and digestive function are affected to some extent, and the postoperative recovery is slow. In addition, a series of complications such as biliary fistula p cholestatic peritonitis, intestinal fistula, biliary tract infection, peri-T-tube infection, slippage, rupture, inflammatory hyperplasia, stricture, etc., may occur when carrying and removing the tube.1 In order to solve the above problems, in recent years, hepatobiliary surgery colleagues have designed various methods, such as preoperative placement of nasobiliary tube2, intraoperative drainage tube built-in3, intraoperative placement of catheter via hepatobiliary duct4, and drainage tube via gallbladder duct 5 etc., although partially ameliorating the problem of complications with T-tubes, they also have their own drawbacks and pose corresponding new problems. Conventional access exploration with one-stage suture, although it can reduce postoperative complications 6, still has the risk of bile duct stricture due to the large damage to the common bile duct. In view of this, after mastering the techniques of intraoperative and postoperative application of choledochoscopy, our hospital began to perform biliary exploration via the choledochal duct approach in 20 cases in 1996 for some suspected biliary abnormalities, such as intraoperative thickening of the common bile duct by R1.2 cm, or a history of biliary pancreatitis or transient jaundice without special findings on preoperative imaging, including ultrasound and CT, but only 14 cases were successful. Although this approach has the advantage of not damaging the common bile duct, it is extremely difficult to deliver and examine the choledochoscope due to the influence of the gallbladder neck, the spiral flap in the duct, the thin inner diameter of the cystic duct, and the acute angle between the confluence of most of the cystic duct and the common hepatic duct, and it is even more difficult to retrieve stones through this approach, and sometimes the traditional method has to be used instead. In some cases, the biliary tract had to be explored by traditional methods. In our trial of 20 cases, although the choledochal duct was visually thickened to varying degrees, 6 cases failed, with a failure rate of 33.3%.7 The operation time of choledochoscopy was also more than 30 minutes. Therefore, the clinical application of transcystic ductal access for biliary exploration was greatly limited. In order to solve the above contradictions, after December 1996, we designed our own transcystic ductal confluence microincision access biliary exploration, the confluence of the incision to solve the problem of the diameter of the cystic duct and spiral flap obstruction, lifting the restriction of the confluence of the cystic duct into the angle, enlarging the entrance, up to 3mm + 3mm or more, even the thickest outside diameter of the current clinical application of 6mm choledochoscope can be freely accessed, conventional stone extraction Even the thickest choledochoscope with an outside diameter of 6mm can be freely accessed. Since the choledochotomy line is very short (<3mm), it has minimal impact on the blood supply and reduces the risk of common bile duct stenosis after direct (one-stage) suturing. By June 2010, our follow-up results of 72 cases of biliary exploration using this procedure verified the above idea and shortened the postoperative hospital stay. (2) Key points of operation technique: After conventional removal of the gallbladder, the stump of the cystic duct requires more than 10 mm, local freeing and confirmation of the connection between the wall of the cystic duct and the wall of the common bile duct. In our hospital, there were two cases of postoperative bile leak, which were suspected to be related to this. Then, a longitudinal incision is made through the anterior right wall of the cystic duct to the confluence, and the anterior wall of the common bile duct is incised transversely or longitudinally on the left side of the wall in a downward direction, and the length should be strictly limited to 3 mm or less. The exploration and extraction must be performed with the assistance of choledochoscope, and the combination of traditional "blind exploration" and "blind extraction" should be avoided to repeatedly stimulate the common bile duct wall and jugular abdomen and their openings, and to eliminate the repeated extraction and insertion of biliary probes to avoid postoperative edema of the bile duct wall and jugular abdomen opening. In order to reduce the incidence of biliary fistula, the bile duct pressure should be increased due to the obstruction of bile drainage in the near future (3-5 days). When examining the lower end of the common bile duct, it is sufficient to see that the folds of the jugular opening are intact, that the opening is >3 mm in diameter and opens and closes naturally8 , and that the outflow of flushing fluid is unobstructed. Since biliary exploration assisted by choledochoscopy allows direct visualization of the inner wall of the bile duct and the opening of the jugular, there is no need to routinely perform a lateral duodenal peritoneal incision (Kocher’s maneuver). (3) Strictly grasp the indications: Although this approach is suitable for most patients with bile duct stones, especially extrahepatic bile duct stones, but because this approach does not place a T-tube after surgery, it should ensure that no bile duct stones remain, so preoperative imaging and evaluation are crucial, and the hospital must have the basic conditions such as intraoperative choledochoscopy for stone extraction and lithotripter. If intraoperative stones cannot be removed at once, the traditional biliary exploration method should be performed instead, and a T-tube should be placed for drainage. In the author’s opinion, although this approach has many advantages, it cannot completely replace the traditional approach. For multiple bile duct stones in the liver or repeated stone retrieval with difficulty, obstructive jaundice, clear lower bile duct stenosis, and emergency biliary exploration without choledochoscopic assistance, the microincisional approach is not recommended for those who need to leave a T-tube for decompression or establish a T-tube fistula for postoperative stone retrieval.