Laparoscopic Common Bile Duct Exploration for Mirizzi Syndrome: Technical Tips

The first step is to expose the critical view of safety (to the extent possible given the inflammation associated with MS. In this case, the infundibulum was retracted laterally and peritoneum overlying the infundibulum and Calot’s triangle was dissected enough to expose the cystic duct and critical view of safety. A cholangiogram was performed utilizing a 4.5Fr Taut Cholangiogram Catheter (Cook Medical; Bloomington, Indiana) via a 14-guage angiocath placed in the right upper quadrant. Cholangiography revealed a dilated cystic duct and a large filling defect at the confluence of the cystic duct and common bile duct. The proximal hepatic duct was dilated however the distal common bile duct was normal caliber, suggesting MS. There were also multiple stones in the distal common bile duct.

Depending on the size of the stone, transcystic choledochoscopy with stone extraction may be feasible. However, if the stone is large (>1cm), choledochotomy may be necessary. If the original ductotomy was over the stone, it can be extended medially to facilitate stone extraction. Intraoperative ultrasound may also be useful to determine the optimal location for the choledochotomy.

The peritoneum overlying the common bile duct is incised to expose the anterior surface. An area on the anterior surface is identified for choledochotomy. Two stay sutures (3-0 PDS) are placed on the medial and lateral aspects to allow for retraction. A longitudinal choledochotomy is made to avoid compromising the blood supply which usually runs at the 3:00 and 9:00 position.

Common bile duct exploration is carried out with a series of Fogarty balloons (5Fr and 6Fr). The duct can be flushed with laparoscopic irrigation in order to dislodge the stone. In the event of MS, it may be necessary to extend the choledochotomy to directly remove the impacted stone as in our case. Choledochoscopy is performed to ensure adequate visualization of the entire duct. This is done with a 7 Fr. choledochoscope attached to a separate video tower. The choledochoscope is passed into the duodenum and slowly withdrawn while circumferentially inspecting the duct to ensure no retained stones.

Although primary choledochotomy closure is safe for most common bile duct explorations, closure over a t-tube (14Fr) may be useful depending on the extent of inflammation in MS. Completion cholangiogram through the t-tube is performed to again ensure complete clearance of the duct. Choledochoscopy may miss a stone at the confluence of the cystic duct and common bile duct (as in this case); therefore, completion cholangiogram via the t-tube may be helpful.

In this case, the t-tube cholangiogram revealed a second larger stone at the confluence of the cystic duct and common bile duct; therefore, the choledochotomy was extended inferiorly and a larger (>1cm) stone was removed. Repeat choledochoscopy was performed and the t-tube was reinserted and secured into the common bile duct. A 10 Fr. Jackson Pratt drain was placed in the right upper quadrant along the choledochotomy site.

Additional Author Notes: the t-tube is a 14 Fr, placed with interrupted 4-0 PDS sutures on RV-1 needle. The tube should be left in 6 weeks and a T-tube cholangiogram should be done prior to removal to confirm clearance of the duct. 

Mirizzi syndrome (MS) is a rare complication of gallstones occurring in 0.2% to 1.5% of patients. The syndrome is defined as a mechanical obstruction of the common hepatic duct from stones impacted in the gallbladder neck or the cystic duct causing extraluminal compression. Despite the use of endoscopic retrograde cholangiopancreatography (ERCP), pre-operative diagnosis is classically difficult and approximately one half of patients are diagnosed intra-operatively.

Traditionally, MS has been treated with open cholecystectomy due to the inflammation and fibrosis encountered during the dissection of Calot’s triangle; however the use of laparoscopy continues to expand in the treatment of gallbladder disease. In 1992 the first successful laparoscopic treatment of MS was reported. Since that time, several cases have been described. Here we describe technical tips to perform laparoscopic cholecystectomy with common bile duct exploration in the presence of MS.

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A 10 mm Hasson trocar was placed in the supraumbilical region via direct cut-down technique. A 5 mm port was placed at the right anterior axillary line, at the level of the umbilicus, to retract the gallbladder. A 5mm port in the right mid-clavicular line, superior to the level of the umbilicus, and a 10mm epigastric port at the level of the falciform ligament were placed for the surgeon’s left and right hands, respectively. An additional 5 mm port was subsequently placed in the right anterior axillary line in the subcostal area for the choledochoscope and a 5mm left upper quadrant trocar was placed to facilitate suturing.

The patient is a 44 year old male with no significant medical history who presented to the Emergency Room with right upper quadrant pain and jaundice. On exam he was afebrile with a minimally tender abdomen. Labs were significant for total bilirubin of 7.6 (direct = 7.1), alkaline phosphatase 404, AST/ALT of 47/87, and WBC of 6. CT scan revealed 1cm stone in the proximal common bile duct with proximal biliary dilation and multiple stones in the gallbladder. The patient was admitted to Medicine by the ER service and GI was consulted for ERCP. ERCP revealed a filling defect “consistent with a stone” near the cystic duct-common duct junction; however the stone was unable to be retrieved. Stents were placed and surgery was consulted for further management.

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