Laparoscopic management of Mirizzi syndrome type IV: a case report and review of minimal access surgery

Abstract

Mirizzi syndrome type IV, a rare and complex form of biliary obstruction, has traditionally required major open surgery. This case report describes a groundbreaking alternative: a 44-year-old woman successfully treated using a minimally invasive laparoscopic approach. The less invasive procedure resulted in rapid, complication-free recovery, with no evidence of biliary stricture at the 6-month follow-up. This outcome challenges conventional management and demonstrates that a minimally invasive approach can be both feasible and highly effective in carefully selected patients.

INTRODUCTION

Mirizzi syndrome (MS), a rare complication of cholelithiasis, causes obstructive jaundice due to gallstone impaction in the cystic duct or Hartmann’s pouch, leading to common hepatic duct compression [1]. First described by Kehr in 1905 and later named by Mirizzi, MS presents with nonspecific symptoms, making diagnosis challenging [2]. Classified into five types, MS type IV, the least common, typically requires bilioenteric anastomosis [3,4]. An endoscopic retrograde cholangiopancreatography (ERCP) diagnosed the MS type IV, and a laparoscopic cholecystectomy (LC) with fistula closure was performed. This report complies with the SCARE (Surgical CAse Report) guidelines [5].

CASE REPORT

A 44-year-old female presented with chronic right upper quadrant pain, anorexia, and jaundice, but no fever or weight loss. Her medical history included hypertension and gallstones diagnosed over 2 years prior, without symptomatic episodes or follow-up. Physical examination revealed stable vital signs, scleral icterus, and right upper quadrant, and epigastric tenderness with guarding and rebound. Laboratory tests showed elevated inflammatory markers (C-reactive protein, 22.49 mg/L; white blood cells, 10.4 × 10⁹/L), cholestasis (gamma-glutamyl transferase, 1,435 U/L; total bilirubin, 108.68 μmol/L; conjugated bilirubin, 66.91 μmol/L), hepatic cytolysis (aspartate aminotransferase, 380 U/L; alanine aminotransferase, 280 U/L), and elevated pancreatic markers (urinary amylase, 1,380 U/L).

Abdominal ultrasound revealed proximal biliary tract dilation and a 19mm common bile duct stone. The gallbladder showed wall thickening (6 mm) and calcifications, suggestive of chronic cholecystitis. Computed tomography confirmed intrahepatic and common hepatic duct dilation, and a large (17 × 20 × 28 mm) calculus obstructing the cystic duct junction, with distal common bile duct tapering (Fig. 1).

Fig. 1.

Computed tomography scan showed a dilated cystic duct with a large stone (yellow arrow) stuck at the location where the cystic duct empties into the common bile duct. (A) Axial plane view. (B) Coronal plane view.

The patient was diagnosed with acute cholangitis and chronic calculous cholecystitis. Empirical cefoperazone 2 g was initiated. ERCP revealed a cystic duct stone eroding into the common hepatic duct, confirming MS type IV (Fig. 2). Cholangioscopy confirmed the impacted stone at the cystic duct-common bile duct confluence, chronic inflammation, cystic duct dilation, and biliary ductal destruction. During the ERCP, a retrieval basket became entrapped with the stone, requiring further intervention.

Fig. 2.

Cholangiography showed a large stone stuck (white arrow) at the location where the cystic duct empties into the common bile duct.

Emergency surgery was indicated for acute cholangitis, chronic calculous cholecystitis, and MS type IV. LC and choledochoplasty with fistula closure were performed using four trocars (two 10 mm, two 5 mm) and pneumoperitoneum (8–10 mmHg CO₂). Intraoperatively, chronic cholecystitis with cystic duct dilation was observed. The large obstructing calculus and entrapped retrieval basket were removed from the widened cystic duct-common bile duct fistula. Cholangioscopy confirmed no residual stones. The cystic duct was ligated and divided with 1-0 polyglactin 910 sutures. After the gallbladder removal, the fistula was repaired with 3-0 polyglactin 910 sutures. An 18-French T-tube was inserted into the common bile duct through the repaired choledochotomy site to ensure drainage and allow for postoperative cholangiography, and a subhepatic drain was placed. The entire procedure was completed laparoscopically (Fig. 3).

Fig. 3.

Intraoperative and postoperative findings. (A) Abdominal distension after endoscopic retrograde cholangiopancreatography. (B) A large calculus within the cystic duct (yellow arrow) and cystic duct incision (white arrow). (C) Cholangioscopy confirming no residual stones (white arrow). (D) Closure of the cystic duct incision using polyglactin 910 suture (1-0) (white arrow). (E) Post-suture cystic duct (yellow arrow) with insertion of a T-shaped tube into the common bile duct through the repaired choledochotomy site (white arrow). (F) Suturing after placement of a Kehr tube (white arrow) and gallbladder removal (dashed line).

Postoperative recovery was uneventful. The patient was discharged on day 5 and remained asymptomatic at a two-week follow-up. A T-tube cholangiography showed no residual stones (Fig. 4). The T-tube was removed one month postoperatively. At the 6-month follow-up, the patient was still asymptomatic with no signs of biliary stricture, confirming the successful long-term repair.

Fig. 4.

T-tube cholangiography showed the biliary tree as the normal size of the common bile duct and the contrast in the intestines.

DISCUSSION

LC is the standard treatment for symptomatic cholelithiasis. However, LC can be challenging for gallstones outside the gallbladder or those with fistulous communication. Preoperative MS identification is crucial for surgical planning and complication reduction [6]. Management strategies vary significantly across MS types [4,7]. Several classification systems for MS have been described in the literature, among which the McSherry and Csendes classifications are the most commonly used; however, the Csendes is the only validated and most acceptable classification [3,4].

According to this system, MS is categorized into five types based on the presence and extent of fistulas, each with varying reported incidences. Type I (incidence of 10.5%–78%) is characterized by extrinsic compression of the common hepatic or common bile duct by a stone impacted in the cystic duct or gallbladder neck. Types II (15%–41%), III (3%–44%), and IV (1%–4%) involve a cholecystobiliary fistula encompassing less than one-third, between one-third and two-thirds, and the entire circumference of the bile duct wall, respectively. Specifically, type IV represents a complete fusion of the biliary structures with no recognizable dissection planes. Finally, type V (incidence up to 29%) is defined by the presence of a cholecystoenteric fistula in addition to any of the aforementioned types.

For MS type I, an LC is usually feasible. Types II and III are more complex, often requiring partial cholecystectomy or fistula closure, with a higher chance of converting to open surgery.

Our case represents MS type IV, which is characterized by complete destruction of the common bile duct wall due to fistula formation. Traditionally, MS type IV has been considered a contraindication for laparoscopic surgery, with open surgery and bilioenteric anastomosis (typically hepaticojejunostomy) being the standard of care due to the extensive nature of the biliary defect and the high risk of iatrogenic injury [4,7].

Despite these traditional views, there is a growing interest in minimally invasive approaches for complex biliary pathologies, including higher types of MS. Zhao et al. [1] conducted a systematic review on the safety and feasibility of laparoscopic approaches for MS, suggesting that while challenging, laparoscopic surgery can be performed in selected cases, with outcomes comparable to open surgery in terms of hospital stay and complications, although conversion rates remain a concern, especially for complex types. Nag et al. [8] also reported a case series on laparoscopic management, highlighting the intra-cholecystic approach as a potential strategy for difficult cases.

Despite the surgical complexity, an LC was successfully performed. The impacted stone was removed, and the fistula was meticulously repaired. A T-tube was inserted for drainage and to ensure patency. The patient had an uneventful recovery. A 6-month follow-up revealed no signs of biliary stricture, confirming the successful long-term durability of the repair. This outcome supports the potential for minimally invasive techniques in carefully selected MS type IV cases.

The role of minimally invasive surgery in MS type IV remains controversial and largely depends on the surgeon’s experience, intraoperative findings, and the extent of inflammation. While our case demonstrates the successful application of a laparoscopic approach, it is crucial to acknowledge that bilioenteric anastomosis may still be necessary in many type IV cases, particularly when the common bile duct defect is extensive or tissue quality is poor. The lack of a universally established consensus on the optimal classification and management algorithm for MS, as noted by Kulkarni et al. [9] and Testini et al. [10], further emphasizes the need for individualized treatment plans and continued reporting of diverse case experiences. Our case adds to the limited literature supporting a less invasive approach for MS type IV in carefully selected patients, potentially offering benefits like reduced pain and shorter hospital stays compared to open surgery.