Type IV Mirizzi Syndrome Treated with Hepaticoduodenostomy and Minilaparoscopy

Gustavo Lopes de Carvalho, MD, PhD, Gilberto Fernandes Silva de Abreu, MD, MSc, Diego Laurentino Lima, MD, Gustavo Henrique Belarmino de Góes, Medical Student

Faculty of Medical Sciences (all authors) and University of Pernambuco (UPE), Recife, Brazil (Dr. Carvalho).


Introduction: Mirizzi syndrome (MS) is an uncommon complication of long-term chronic cholecystitis, characterized by extrinsic compression of the common hepatic duct or the presence of cholecystobiliary fistula. A case of type IV MS, with extensively damaged common hepatic duct (CHD) due to gallstone impaction and fistula, was effectively treated by minilaparoscopic hepaticoduodenostomy (HD).

Case Description: The patient was a woman, 36 years old, weighing 66 kg, and standing 1.55 m. For 3 weeks, she had been experiencing episodes of strong right-upper-quadrant pain, radiating to the back. She also presented with choluria, fecal acholia, and severe jaundice. Preoperative magnetic resonance cholangiopancreatography (MRCP) suggested the diagnosis of Mirizzi syndrome (MS). Surgery started with “dome-down” dissection of the gallbladder. The cystic duct and the CHD were found to be highly compromised close to the gallstone impacted in the infundibulum. After resection of the affected bile ducts, the biliary tract reconstruction was performed by minilaparoscopy (MINI). The patient was discharged uneventfully 6 days after surgery, without complication.

Discussion: Because of the severely compromised CHD, HD was the technique used for reconstruction, for its simple execution, and several proven advantages over hepaticojejunostomy. It was performed by MINI, a new, effective, and refined minimally invasive technique in which the surgeon uses low-friction trocars to improve visualization and dexterity in delicate surgical tasks. A Kocher maneuver was necessary to make possible this type of reconstruction.

Conclusion: There is no consensus yet about the best type of reconstruction to use for a severely damaged CHD. In the present case, HD by MINI proved to be a safe and effective method, emphasizing its known advantages.

Key Words: Biliary fistula, Biliary reconstruction, Biliary tract injury, Hepaticoduodenal anastomosis, Hepaticoduodenostomy, Hepaticojejunostomy, Microlaparoscopy, Minilaparoscopy, Mirizzi syndrome type IV, Needlescopic surgery.

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