We present the case of a 67-year-old female with recent cholecystectomy for symptomatic cholelithiasis. She was admitted to our hospital with right upper quadrant abdominal pain and vomiting. Laboratory analysis revealed hyperbilirubinemia with cytolysis and cholestasis. Abdominal ultrasound revealed a choledocholithiasis of 8 mm. Endoscopic retrograde cholangiopancreatography (ERCP) was scheduled. With the duodenoscope, after the reduction maneuver from the second duodenal portion to face the major papilla, a perforation of approximately 18 mm was identified in the contralateral wall distal to it. A gastroscope identified the perforation and a 9.5-11 x 6 mm over-the-scope-clip (OTSC) was placed after inserting its edges into the cap with aspiration (without approximation forceps).