Laparoscopic approach is safe and effective in the management of Mirizzi syndrome

Mirizzi Syndrome: Clinical Insights, Diagnostic Challenges, and Surgical Outcomes - A 5-Year Experience from a Tertiary Care Hospital in Pakistan

Background

Mirizzi syndrome (MS) is a rare condition in which the common bile duct or hepatic duct is blocked by impacted gallstones. It can cause symptoms such as cholecystitis, including abdominal pain, nausea, and vomiting. Although diagnosis is challenging, imaging techniques such as ultrasonography and CT scans are helpful. The gold standard for diagnosis is ERCP (Endoscopic Retrograde Cholangiopancreatography). Surgical management is the primary treatment, with laparotomy preferred over laparoscopic procedures.

Methodology

This prospective study was conducted over a period of five years at a tertiary care hospital in Pakistan. A total of 72 patients, aged 21-70 years (mean age 44.81 years), with symptomatic cholelithiasis were included. All patients underwent ultrasonography and, in selected cases, MRCP (Magnetic Resonance Cholangiopancreatography) and ERCP were performed preoperatively. MS was detected preoperatively in 19.4% of cases and intraoperatively in the remaining cases. Data were analyzed using SPSS version 28.

Results

Of the 72 patients, 75% were female. Most patients (69.4%) presented with the right hypochondrium pain, while 16.7% presented with pain and jaundice. Preoperative liver function tests were abnormal in 44.4% of patients. Imaging techniques used included ultrasound (100% of patients), MRCP (22.2%), and ERCP (8.3%). Laparoscopic cholecystectomy was completed in 63.8% of patients, with a conversion rate to open surgery of 30.55%. Two patients required open cholecystectomy with hepaticojejunostomy due to gallstone ileus. The MS types identified were type I (50%), type II (25%), type III (19.4%), type IV (2.77%), and type V (2.77%).

Conclusion

MS is a rare and challenging condition to diagnose. Although imaging techniques are helpful, ERCP remains the gold standard. Surgical management, particularly laparoscopic cholecystectomy, is effective but requires careful implementation by experienced surgeons to avoid complications. In complex cases, laparotomy remains a necessary option.

Clinical Outcomes and Treatment Strategy of Mirizzi's Syndrome Treated With Surgery

BACKGROUND

There is currently no standardized treatment for Mirizzi's syndrome (MS). We aim to explore the surgical treatment strategy for MS by analyzing its clinical characteristics and treatment outcomes.

METHODS

This retrospective study analyzed the clinical data of 130 patients with MS who underwent surgery at our hospital from April 2013 to April 2020.

RESULTS

The study population comprised 130 patients with MS, with an approximately balanced sex ratio and a median age of 58.5 years. The preoperative diagnostic rate was 82.3%. The diagnostic accuracy of ERCP was 92.5%, higher than that of MRCP and ultrasound. All patients underwent surgical treatment, with 74 cases of laparoscopic surgery, 43 cases of laparotomy, and 13 cases of laparoscopic surgery converted to laparotomy. A total of 23 patients experienced short-term and long-term complications after surgery, with a complication rate of 17.7%. There was no statistical difference between laparoscopic surgery and open surgery in terms of intraoperative hemorrhage, operative time, and postoperative complication rate. However, the length of hospital stay was shorter in the laparoscopic surgery compared to the open surgery, which was statistically different from each other.

CONCLUSION

ERCP is the gold standard for the diagnosis of MS, especially for identifying the type of MS. ERCP plays an important role in both the preoperative and postoperative phases of MS. Our study demonstrated that laparoscopic surgery was a safe and feasible option for MS treatment, even requires less hospitalization than open surgery.

Mirizzi syndrome: Problems and strategies

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

Mirizzi Syndrome-The Past, Present, and Future

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Laparoscopic treatment of Mirizzi syndrome with subtotal cholecystectomy and electrohydraulic lithotripsy: A case report

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Endoscopic retrograde cholangiopancreatography-oriented surgery for accomplished treatment of Mirizzi syndrome: a single-center experience

BACKGROUND

Mirizzi syndrome is a gallstone disease characterized by compression of extrahepatic biliary duct with an impacted stone. Our aim is to identify and describe the incidence, clinical presentation, operative details and the association postoperative complication of Mirizzi syndrome in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The ERCP procedures were held in Gastroenterology Endoscopy Unit and retrospectively evaluated. The patients were divided into two groups, the cholelithiasis + common bile duct (CBD) stone group and the Mirizzi syndrome group. These groups were compared with the demographic characteristics, ERCP procedures, types of Mirizzi syndrome and surgical technique.

RESULTS

A total of 1018 consecutive patients who underwent ERCP were scanned retrospectively. Of the 515 patients fulfilling the criteria for ERCP, 12 had Mirizzi syndrome and 503 had cholelithiasis and CBD stones. Half of the Mirizzi syndrome patients were diagnosed with pre-ERCP ultrasonography. The mean diameter of choledoc was found to be 10 mm in ERCP. ERCP-related complication rates (pancreatitis, bleeding and perforation) were the same in the two groups; 66.6% of the Mirizzi syndrome patients applied cholecystectomy and placement of T-tube surgical procedures, and there were no postoperative complications.

CONCLUSION

Surgery is the definitive treatment of Mirizzi syndrome. Thus patients should have a correct preoperative diagnosis for an appropriate and safe surgery. We think that ERCP could be the best guide for this. Also, we believe that intraoperative cholangiography with ERCP and hybrid procedures for guiding surgical treatment may become an advanced treatment option in the future.

Type IV Mirizzi Syndrome: Brief Report and Review of Management Options

Mirizzi syndrome is a rare complication of chronic calculous cholecystitis. Preoperative diagnosis is challenging due to the absence of pathognomonic signs and symptoms and low sensitivity rates of imaging tests. Historically, laparotomy has been the preferred choice of surgical management. Endoscopic and laparoscopic approaches have been increasingly described as diagnostic and therapeutic options for Mirizzi type I and II, but data is limited regarding the management of more complex cases. We describe a staged endoscopic and laparoscopic approach for the management of type IV Mirizzi syndrome and review the management options.

Surgical strategies for Mirizzi syndrome: A ten-year single center experience

BACKGROUND

Mirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.

AIM

To analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.

METHODS

The clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.

RESULTS

Sixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).

CONCLUSION

MRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.

The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome

Mirizzi syndrome occurs in up to 6% of patients with cholecystolithiasis. It is generally caused by external compression of the common hepatic duct by a gallstone impacted in the neck of the gallbladder or the cystic duct, which can lead to fistulisation. The aim of this review was to highlight the proposed classifications for Mirizzi syndrome (MS) and to provide an update on modern approaches to the diagnosis of this disease. We conducted research on various internet databases and the total number of records was 993, but after a gradual process of elimination our final review consisted of 21 articles. According to the literature, the Cesendes classification is the most commonly used, but many new suggestions have appeared. Our review shows that the ultrasonography (US) is the most frequently used method of initial diagnosis, despite still having only average sensitivity. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are good methods and are similarly effective, but only the latter can be simultaneously therapeutic. Some modern methods show very high sensitivity, but are not so commonly administered. Mirizzi syndrome is still a diagnostic challenge, despite the advancement of the available tools. Preoperative diagnosis is crucial to avoid complications during treatment. New research may bring a unification of classifications and diagnostic algorithms.

One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units

BACKGROUND

To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks.

METHODS

Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones.

RESULTS

38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals.

CONCLUSION

Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality.

A case of obstructive jaundice without biliary stones in a low resource setting

Although not common, Mirizzi's syndrome (type 1) is a differential diagnosis in a patient with cholecystitis and obstructive jaundice, after a thorough clinical assessment. The jaundice would be resolved by cholecystectomy.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review

BACKGROUND

Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility.

METHODS

We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed.

RESULTS

From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5 min to 270.5 ± 65.5 min, and the mean intraoperative bleeding varied from 21.1 ± 15.9 ml to 162.81 ± 40.83 ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61 days. Postoperative complications occurred in 27 patients.

CONCLUSIONS

Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

Laparoscopic subtotal cholecystectomy for Mirizzi syndrome: A report of a case

INTRODUCTION

Mirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome.

PRESENTATION OF CASE

A 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful.

DISCUSSION

After laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment.

CONCLUSION

Laparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.

Role of Laparoscopic Surgery in the Current Management of Mirizzi Syndrome

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach ( P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.

Current trends in the management of Mirizzi Syndrome: A review of literature

Mirizzi Syndrome is a rare and challenging clinical entity to manage. However, recent advances in technology have provided surgeons with new options for more effective diagnosis and treatment of this condition. This paper reviews these new diagnostic modalities and treatment approaches for the management of Mirizzi Syndrome.An online search language was performed using PubMed and Web of Science for literature published in English between 2012 and 2017 using the search terms "Mirizzi Syndrome" and "Mirizzi." In total, 16 case series and 11 case reports were identified and analyzed.The most frequently used diagnostic modalities were ultrasound, computed tomography (CT); magnetic resonance cholangiopancreaticography (MRCP); endoscopic retrograde cholangiopancreaticography (ERCP). A combination of ≥2 diagnostic modalities was frequently used to detect Mirizzi Syndrome. Literature shows that the specific type of Mirizzi Syndrome determined the type of treatment chosen. Open surgery was the preferred option, although there are documented cases of the use of minimally-invasive techniques, even in advanced cases. Laparoscopic, endoscopic or robot-assisted surgery, used individually or in combination with lithotripsy, were all associated with a favorable outcome.As yet, there are no internationally-accepted guidelines for the management of Mirizzi Syndrome. Laparotomy is the preferred surgical technique of choice, although an increasing number of surgeons are beginning to opt for minimally-invasive techniques. The number of papers in the existing literature describing diagnostic and treatment procedures is relatively small at present, thus making it difficult to reasonably propose an evidence-based standard of care for Mirizzi Syndrome.

Mirizzi syndrome: necessity for safe approach in dealing with diagnostic and treatment challenges

Backgrounds/Aims

The challenging dilemma of Mirizzi syndrome for operating surgeons arises from the difficulty to diagnose it preoperatively, and approximately 50% of cases are diagnosed intraoperatively. In this study, we analysed the effectiveness of diagnostic modalities and treatment options in our series of Mirizzi syndrome.

Methods

Patients had a preoperative or intraoperative diagnosis of Mirizzi syndrome, and were classified into three groups: Group 1: Incidental finding of Mirizzi syndrome intraoperatively (n=34). Group 2: Patients presented with jaundice, diagnosed by endoscopic retrograde cholangiopancreatography (n=17). Group 3: Patients diagnosed initially by ultrasound (n=13). Laparoscopic cholecystectomy was conducted in all 49 patients with Cendes type I disease. Partial cholecystectomy, common bile duct exploration, repair of fistula and t-tube placement was conducted on eight patients with Cendes type II and five patients with Cendes type III. Partial cholecystectomy with Roux-en-Y hepaticojejunostomy was conducted in two patients with Cendes type IV disease.

Results

Sixty-four patients were diagnosed with Mirizzi syndrome. Morbidity rate was 3.1%. Mortality rate was 0%. Group 3 (patients diagnosed initially by ultrasound) had the best treatment outcome, the least morbidity, and the shortest hospital stay.

Conclusions

Suspected cases of Mirizzi syndrome should not be underestimated. Difficulty in establishing preoperative diagnosis is the major dilemma. As it is mostly encountered intraoperatively, the approach should be careful and logical to identify the correct type of Mirizzi by a thorough diagnostic laparoscopy and thus, provide optimum treatment for the subtype to achieve the best outcome.

Mirizzi syndrome: a new insight provided by a novel classification

BACKGROUNDS/AIMS

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease.

METHODS

A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes.

RESULTS

28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none.

CONCLUSIONS

Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.

Performing the Difficult Cholecystectomy Using Combined Endoscopic and Robotic Techniques: How I Do It

Laparoscopic cholecystectomy is the standard of care for cholelithiasis as well as cholecystitis. However, in the setting of Mirizzi syndrome or gangrenous cholecystitis where the critical view cannot be ascertained, subtotal cholecystectomy may be necessary. Using the robot-assisted approach, difficult cholecystectomies can be performed upfront without need for partial cholecystectomy. Even in the setting of Mirizzi syndrome where severe scarring and fibrosis are evident, definitive cholecystectomy and takedown of the cholechystocholedochal fistula can be performed in a safe and feasible fashion following successful endoscopic common bile duct stent placement. The purposes of this report are to review the history of Mirizzi syndrome as well as its traditional and novel treatment techniques and highlight technical pearls of the robotic approach to this diagnosis.