Sujit Kulkarni, MD; David Vivas, MD; Paresh C. Shah, MD
Introduction: Mirizzi's syndrome refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct. It is a surgically challenging problem and difficult to approach. We present a video of a 60 year old female who presented to emergency room with mild abdominal discomfort, pruritus and jaundice without fever or sepsis. Sonography showed a 1.6 cm gallstone at the neck of gallbladder with common hepatic duct dilation to 1cm. The CBD was 3mm.
Methods: Two attempts at ERCP were unsuccessful in extraction or dislodgement of the stone. A 5Fr stent was placed alongside of the stone allowing decompression of the common hepatic duct. Patient developed post ERCP pancreatitis, which was managed medically and delayed surgical intervention. An MRCP confirmed findings of Mirizzi's syndrome. After resolution of pancreatitis, patient was brought back for an elective laparoscopic CBD exploration. Intra-operatively she was found to have a sclerotic and contracted gallbladder and a type-3 Mirizzi's with fistulization to the common hepatic duct. Laparoscopic common bile duct exploration was performed with extraction of the stone. Primary reconstruction of common hepatic duct and common bile duct was completed over a T-tube.
Results: The post-operative course was unremarkable. The T-tube was removed at six weeks after repeat cholangiogram.
Conclusion: Laparoscopic management of Mirizzi's syndrome is feasible and safe. Preoperative and intra-operative assessment of anatomy by cholangiography is critical. Fistula formation requires a complete CBDE and the inflammatory changes present in the wall make T-tube reconstruction essential.