Technique of en-bloc ampullectomy of a granular/villiform exophytic ampullary adenoma. A: lesion is identified and margins carefully assessed; B: with the snare tip anchored above the papillary mound the entire papilla is ensared; C: check mobility and ensure the snare is firmly closed; D: en-bloc ampullary resection is performed; E: pancreatic orifice is identified and cannulated; F: short, 5Fr pancreatic stent placed; G: ampullectomy specimen; H: cholangiogram with no evidence of IDE.