Background Up to 15% of patients with cholelithiasis have choledocholithiasis, with almost 10% not detected pre-operatively. Our study aims to quantify the prevalence of incidental choledocholithiasis during routine intra-operative cholangiogram (IOC), identify the best management pathway and reliable pre-operative predictive factors. Methods We performed a single centre, retrospective cohort study at St John of God Midland Hospital in Western Australia, Perth on 880 consecutive patients undergoing cholecystectomies by 15 surgeons between 2 January 2020 to 30 December 2021. Results Overall choledocholithiasis rates were 10.6% (93), with 4.0% (35) diagnosed pre-operatively and 6.6% (58) diagnosed during IOC. 50% of incidental choledocholithiasis during IOC was managed with hyoscine butylbromide, with 55.2% success rates. 22.4% of patients received Octreotide, with 61.5% success rates. 8.6% of patients underwent trans-cystic bile duct exploration (TCBE) and 8.6% underwent post-operative ERCP, both with 100% success rates. Choledocholithiasis most commonly presents with gallstone pancreatitis, with a median AST 7.2 times and ALT 7.8 times higher than patients without choledocholithiasis. The median CBD diameter on ultrasound was 8mm, CT scan was 11mm and MRCP was 9mm. Conclusion 1 in 10 cholecystectomies will be complicated with choledocholithiasis, and over half will be incidentally diagnosed during routine IOC. We propose intra-operative cholangiogram in all cases and hyoscine butylbromide, octreotide and saline flushes as first line treatment, and if unsuccessful, TCBE. Gallstone pancreatitis, markedly elevated AST/ALT and imaging showing CBD ≥ 8mm may serve as early predictors of choledocholithiasis.