Purpose: This retrospective review of a prospectively collected database investigated the occurrence of positive intraoperative cholangiograms in laparoscopic cholecystectomy patients with negative preoperative imaging for choledocholithiasis. The study assessed recommended approach for stone detection.Additionally, it explored differences in outcomes for patients who underwent preoperative endoscopic retrograde cholangiopancreatography versus postoperative ERCP. Methods: Over a 14-week period, 182 patients undergoing laparoscopic cholecystectomy were prospectively enrolled, categorized into three groups: a) suspected stones without preoperative intervention, b) suspected stones with preoperative ERCP, and c) negative preoperative imaging with positive IOC. We calculated treatment plans, complication rates, readmissions within 30 days, LOS, and the positive predictive value (PPV) of preoperative imaging for ductal stones. Results: Among 16 patients with positive preoperative imaging, 37.5% underwent preoperative ERCP, and 12.5% required postoperative ERCP, revealing a 37.5% PPV for preoperative imaging. Notably, 62.5% proceeded directly to laparoscopic cholecystectomy, with 20% requiring postoperative ERCP upon positive IOC findings. Those with preoperative ERCP had LOS ranging from 1 to 4 days. Among 26 patients with positive IOCs, 19.2% had positive preoperative imaging. Of those without preoperative evidence, 88.5% had small stones managed intraoperatively, and 11.5% required postoperative ERCP, resulting in longer LOS (2, 3, 9 days). Conclusion: Routine IOC is crucial.This emphasizes the surgeon's responsibility not only within the surgical system but also in the broader healthcare community.The study's small size limits decision-making robustness.