Currently, the maturation and development of endoscopic technology has created a new era of minimally invasive surgical techniques, which has challenged traditional surgical procedures. LC has become the gold standard for minimally invasive surgical treatment of gallbladder stones, but for gallbladder stones with bile duct lesions (such as stones), although there are treatment methods to perform common bile duct exploration and stone extraction at the same time of LC, it is still difficult to be popularized due to the equipment and technical conditions. Although there is a method for simultaneous bile duct exploration and stone extraction in LC, it is not yet widely available due to equipment and technical conditions. In contrast, the management of benign biliary lesions via ERCP is technically proficient and efficacious. Therefore, the use of ERCP combined with LC has become the choice of minimally invasive treatment for gallbladder stones with biliary lesions. 1. The order of ERCP and LC procedures LC combined with ERCP treatment is still clinically controversial. Those in favor of LC followed by ERCP believe that LC may drop small gallbladder stones into the bile duct, and ERCP after LC can avoid residual bile duct stones. Our opinion is in favor of the combined approach of ERCP followed by LC, for the following reasons: (1) bile duct variation is not uncommon, and ERCP can obtain good imaging data of the biliary tree, which can be used as a guide for LC to avoid bile duct injury; (2) ERCP can clarify the lesions of the bile ducts inside and outside the liver, and once bile duct stones or strictures are found, EST can be performed to cut the strictures and retrieve stones, even if small stones fall into the bile ducts after LC. Even if small stones fall into the common bile duct after LC, the wider outlet after EST can make the small stones drain naturally; (3) Pre-operative ERCP imaging data combined with ultrasound results can provide reference for performing LC or not, and reduce the need for intermediate open abdomen. In this group of 27 cases, 25 cases were treated with LC after ERCP, and 2 cases were confirmed by ERCP to have Mirizzi syndrome and low confluence of bile cyst ducts, so LC was abandoned and open surgery was performed instead. 25 cases of LC were treated without conversion to open abdomen and complications, and all were cured. The combination of ERCP and LC has expanded the scope of minimally invasive techniques in the biliary tract, and most patients with gallbladder stones with biliary lesions suitable for ERCP and LC can be treated with this combined approach.Miller et al. concluded that the indications for ERCP before LC are: jaundice, cholestatic pancreatitis of biliary origin, abnormal liver function, ultrasound showing total bile duct stones or dilated common bile duct. We believe that for patients with gallbladder stones with jaundice and abnormal liver function, especially elevated AKP and γ-GT; ultrasound suggesting dilated or undilated common bile duct without stones, should be the main indication for preoperative LC. Since ultrasound is less sensitive for lesions in the lower part of the common bile duct due to the influence of gas in the stomach and intestine, it is easy to miss. It is worth noting that patients with gallbladder stones without jaundice and bile duct dilatation, with only mildly elevated transaminases and significantly elevated AKP and γ-GT, should consider the possibility of stenosis and small stones in the lower bile duct, and ERCP should be performed before LC when conditions permit. In our group, there were 4 cases without jaundice and no bile duct stones were seen on ultrasound, but AKP and γ-GT were significantly elevated and confirmed as common bile duct stones by ERCP. In view of the low systemic physiological disturbance by ERCP, LC can be performed as long as there is no postoperative fever and abdominal pain and normal blood amylase. Unless the operation time of ERCP is long, repeated intubation and lithotripsy for stone extraction are more disturbing to the biliary tract, LC should be delayed for safety. 3. Prevention and management of ERCP complications Although ERCP and LC techniques have matured, there are still certain complications. Some scholars summarized 142,946 cases of LC, the total complications were 0.71%; while the total complications of ERCP were 4%. ERCP complications are mainly pancreatitis, bleeding, infection and perforation, especially post-ERCP pancreatitis, which is the main reason for the limited application of ERCP. It can be caused mainly by EST, repeated pancreatic duct intubation and high-pressure contrast injection, etc. It is manifested by abdominal pain and distension after ERCP with fever and/or jaundice, and blood amylase is often more than 3 times higher than normal. The occurrence of post-ERCP complications of pancreatitis is not only related to the operator’s operating technique, but there are also high-risk factors in the patients themselves, and even skilled operators can hardly avoid its This has been proven by the results of most foreign studies. Therefore, we believe that in addition to strictly mastering the indications for ERCP and paying attention to the intraoperative and postoperative management of ERCP, it is necessary to standardize the operator’s operating techniques and strengthen the training of operating skills to reduce the complications of ERCP, and the prevention of post-ERCP pancreatitis should be given more attention than its management. (1) Pay attention to the direction of the lower bile duct in the intestinal duct before papillary cannulation to avoid blind cannulation; (2) Inject contrast agent with slow force under fluoroscopy and stop the injection as soon as the pancreatic duct becomes visible; (3) When guiding with a guidewire for difficult cannulation, pay attention to the direction of guidewire travel and try to avoid repeatedly entering the pancreatic duct. Two cases of acute mild pancreatitis occurred in this group and were cured by conservative treatment. In addition to preoperative prophylaxis, postoperative strengthening of anti-infection and the use of enzyme-suppressing agents (gabapentin and sennin), the placement of biliary drainage is a non-negligible treatment tool. In conclusion, ERCP combined with LC is a safe and effective minimally invasive treatment for gallbladder stones with biliary lesions, with less trauma to the patient as well as less systemic physiological interference and faster recovery, and the combined application of both scopes will become the development trend of minimally invasive treatment for most benign biliary tract diseases.