Percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) is a safe and effective method for the treatment of complex intra- and extrahepatic bile duct stones in elderly patients with multiple risk factors. In the case of an 82-year-old man with extensive gallstones and previous abdominal surgery, PTCSL was successfully used to completely remove the stones. The patient had three abdominal surgeries and a coronary stent, which increased the risk of routine surgical procedures. After the procedure, no recurrence of stones was recorded during the one-year follow-up. The authors emphasize the importance of careful preoperative planning and the correct use of surgical instruments to increase the safety and effectiveness of the procedure. This two-step approach represents a new therapeutic option for challenging cases in elderly patients.