Abstract: Objective: To evaluate the therapeutic effect of fiber choledochoscope combined with pneumatic ballistic lithoclasty on refractory residual bile duct stones.Methods: Twenty-one cases of patients with refractory residual bile duct stones,in which T-tube was placed post-operation,were treated by fiber choledochoscope combination with atmospheric pressure ballistic lithoclasty,broken stones then become easy removed.Results: All cases of refractory residual bile duct stones,including gigantic,impacted or cast mould stones,were removed by this procedures without any serious complications.Eighteen cases (85.7%) of stones were completely removed in first time,and only three cases needed another repeated procedures for redundant intrahepatic stones.The operation time was 40-90 minutes without any serious complications.Three days later,the T-tube was removed when complete clearance of stones was confirmed by cholangiography.Conclusions: Fiber choledochoscope combination with pneumatic ballistic lithoclasty is a safe and highly effective method to remove residual bile duct stones that are difficult to be extracted by traditional fiber choledochoscope.