<prompt> A 3 cm size stone in CBD near the ampulla of Vater is removed byTrans duodenal approachSupraduodenal approachChemical dissolutionESWL  <response>: Ans. a Transduodenal ApproachRef: Sabiston 20th edition Page 1501Impacted stones at the ampulla that cannot be removed through choledochotomy or several stones in a nondilated tree can be addressed by a transduodenal sphincteroplastySteps: Kocher maneuver, Longitudinal duodenotomy is made on the lateral wall Palpation of the ampulla to plan placement of the duodenotomy After identifying ampulla- an incision made at 11 O clock Avoid 5O clock as pancreatic duct enters there. The duodenal mucosa is sewn to the bile duct mucosa with absorbable 4-0 sutures. A 1.5cm sphincterotomy is usually sufficient to allow stone removal and subsequent drainage. Closure of the longitudinal duodenotomy in transverse fashion to avoid future duodenal stricture. 