Endoscopic interventions are considered as the mainstay of management of biliary stones. Endoscopic stone extraction using basket and/or balloon catheter after sphincteroplasty is usually performed as conventional method. However, conventional endoscopic methods may be not successful in 10 to 15% of CBD stones. For the effective and successful endoscopic stone removal, papillary dilation or stone fragmentation is demanded for difficult bile duct stones. Mechanical lithotripsy is usual primary modality for stone fragmentation. However, it may be difficult for the impacted stones or very large stones (> 3 cm) because of failure of capturing. And endoscopic papillary large balloon dilation is effective modality for large stones in dilated bile duct with no distal stricture. But, it is not indicated in patients with stricture at distal CBD or impacted stones in non-dilated CBD. Cholangioscopy-guided intraductal lithotripsy is definitely effective modality for difficult bile duct stones. Cholangioscopy-guided interventions may be technically limited and complicated. However, there are innovative recent advances in peroral cholangioscopy (POC). SpyGlass POC system had been recently introduced to overcome the limitation of Mother-baby POC system. It is single-operator POC system with four-way steerability and separate channel for irrigation. Intraductal lithotripsy by SpyGlass POC system was highly successful for difficult bile duct stones. However, it has been underutilized because of the fragility of optic laser probe and expense of the equipment. Direct POC using an ultra-slim upper endoscope is also single-operator POC system using a conventional endoscopic unit. Direct POC provides good image quality, and enable to perform intraductal therapeutic interventions by using various accessories through the 2.0 mm working channel. Direct POC-guided intraductal lithotripsy was also highly successful and very useful for difficult biliary stones in several reports. However, direct POC is performed in selected patients with dilated distal bile duct more than 8 mm. And assisting accessory is required to support and hold the slim endoscope advancing into the bile duct. Balloon catheter is usually used for the successful direct POC. A slim endoscope can be advanced into the bile duct over the anchored balloon catheter in the intrahepatic duct. Recently developing prototype endoscope with multi-bending function is expected to facilitate free-hand direct insertion of an endoscope into the bile duct with no assisting accessory. In conclusion, POC-guided intraductal lithotripsy is very useful and effective for difficult bile duct stones. However, current POC systems require complicated equipment, or are technically demanded. If usual experienced endoscopist can easily perform POC as usual procedure, difficult bile duct stones will be effectively managed.