Mirizzi syndrome, the mechanical obstruction of the common hepatic duct secondary to extrinsic compression of stones impacted in the gallbladder neck or the cystic duct, is a rare complication of cholelithiasis (0.2% to 1.5% of patients). Up to 50% of patients are diagnosed intra-operatively.
We describe technical tips of laparoscopic treatement of Mirizzi Syndrome, including laparoscopic cholecystectomy, common bile duct exploration and stone extraction. Often it is best to fashion the ductotomy over the palpable stone. T tube cholangiogram is also invaluable.
In conclusion, laparoscopic treatment may be used for Mirizzi Syndrome.
Contributor:Dr. Manish Parikh
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 In this case, the infundibulum was retracted laterally and peritoneum overlying the infundibulum and Calot’s triangle was dissected enough to expose the cystic duct and critical view of safety.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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Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
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As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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