Mirizzi syndrome (MS) is a chronic complication of symptomatic gallstone disease that is rare in Western countries, with an annual incidence of less than 1%.¹ However, MS is a more common condition in underdeveloped countries, with a reported prevalence of 4.7% to 5.7% in various populations.^2,3 The importance and implications of MS are related to its associated surgical complications, such as bile duct injury during laparoscopic cholecystectomy.^4,5

Although MS was previously considered an absolute contraindication for laparoscopic cholecystectomy, with the evolution of radiology and increasing familiarity with its pathophysiology, the successful laparoscopic management of MS is now increasingly possible.

A 64-year-old man presented with yellowish discolouration of the sclera and dark-colored urine for 5 days. He did not give any history of hematemesis, clay-colored stools, or bleeding per rectum. He had no comorbidities and described no history of alcohol consumption. Blood investigations—namely, a complete blood count and serum creatinine—were normal. A liver function test (LFT) showed abnormal results (total bilirubin, 7.1 mg/dL; direct bilirubin, 4.5 mg/dL; alanine aminotransferase, 85 IU/L; aspartate aminotransferase, 84 IU/L; alkaline phosphatase, 165 IU/L). The cause of cirrhosis remained unknown.

Imaging studies

Ultrasonography showed altered echotexture of the liver, with a thin-walled gall bladder and a 9-mm stone at the neck.

Contrast-enhanced computed tomography and a computed tomography splenoportogram (Fig. 1) were suggestive of a shrunken liver, mild atrophy of the right lobe with compensatory hypertrophy of the caudate lobe, surface nodularity and irregularity (with an impacted calculus measuring 17 mm seen at the neck of gall bladder), cystic duct and pericholecystic fat stranding, and a common bile duct (CBD) stent in situ. Mild intra-hepatic biliary radical (IHBR) dilatation was seen. The portal vein measured 15 mm. There were few perisplenic, perigastric, and lienorenal collaterals. The spleen was enlarged, measuring 14.5 cm.

Figure 1. A splenoportogram.

Magnetic resonance cholangiopancreatography (Fig. 2) showed a contracted gall bladder with a 17-mm impacted calculus at the neck. There was resultant compression and effacement of the common hepatic duct, representing type 1 MS. Mild dilatation of IHBR was seen in both lobes of the liver. The liver was shrunken with a nodular contour.

Figure 2. Magnetic resonance cholangiopancreatography. IHBR, intrahepatic biliary radical.

Endoscopic retrograde cholangiopancreatography with sphincterotomy with sweeping of the CBD was done. A 10 cm × 10 cm straight plastic stent was placed in the CBD. On follow-up at 2 weeks, the LFT showed a decreasing trend.

After 6 weeks of conservative management, the patient was scheduled for a laparoscopic cholecystectomy (Fig. 3). Indocyanine green (ICG), at a dose of 140 μg (2 μg/kg body weight) was injected intravenously 2 hours prior to surgery. With the patient in the supine position, standard ports were placed according to laparoscopic cholecystectomy. The liver was cirrhotic, and the omentum was adherent to the gall bladder and liver. Collaterals were seen in the ligamentum teres and porta. An extra 5-mm port was placed in the left pararectal region and gauze was used to retract the duodenum. Intraoperatively, a Stryker 1688 camera was used for ICG visualization (Fig. 4). The cystic duct did not illuminate due to obstruction by the stone, but the CBD was visualized. As Calot’s triangle was frozen, a fundus-first approach was performed. The gall bladder was opened at the level of the Hartmann’s pouch, and a 2-cm stone was seen, impacted at the junction of the cystic duct and the common hepatic duct. The stone was disimpacted by milking. Subtotal reconstituting cholecystectomy was performed⁶ to avoid injuring the collaterals between the gall bladder and the liver. The mucosa of the cystic duct stump was cauterized by bipolar cautery to avoid bleeding and closed with polyglactin 2-0. An intra-abdominal no. 28 drain was placed. The post-operative period was uneventful, and the drain was removed after 48 hours. An LFT was repeated after 3 weeks, showing normalized total bilirubin and liver enzyme levels. The CBD stent was removed after 6 weeks.

Figure 3. Laparoscopic cholecystectomy.

Figure 4. Indocyanine green.

MS was previously considered an absolute contraindication for laparoscopic cholecystectomy.⁷ Some reasons for this were the sessile gall bladder, the frozen Calot’s triangle, the recommended fundus-first method, the need to rule out malignancy, and the presence of bilio-enteric fistula. In the few cases where a laparoscopic procedure was attempted, conversion to open cholecystectomy was required because of a bile duct injury or the threat thereof.^8,9 Today, with advances in radiology and increasing familiarity with the pathophysiology, successful laparoscopic management of MS is now being increasingly reported.^10–13 It is sometimes necessary to insert extra ports in addition to the conventional ones due to difficult anatomy.^12,13

Intraoperative cholangiography is very helpful in these complex situations.¹³ Patankar et al¹⁴ studied the efficacy of ICG to visualize the biliary anatomy and established that the use of intravenous ICG helps in CBD visualization. ICG fluorescence allowed the successful visualization of at least one biliary stricture in 100% of cases.

The most common complication of MS is cholecystoenteric or cholecystobiliary fistula formation because of prolonged inflammation. With a prolonged procedure time, other surgical complications may also occur due to dense adhesions, including bile duct injury and hemorrhage. Cutaneous fistula formation, secondary biliary cirrhosis, and delayed-onset biliary strictures are some of the other complications of prolonged inflammation that can be seen in patients with MS.¹⁵

The only prior published study on this topic was by Troum et al,¹⁶ who reported a case of MS in decompensated alcoholic liver cirrhosis in a 71-year-old patient. The patient had cirrhosis, with portal hypertension, splenomegaly, and significant ascites, and underwent open cholecystectomy.

In conclusion, MS with liver cirrhosis is a rare entity. The presence of cirrhosis and periportal collaterals increase the difficulty of performing laparoscopic cholecystectomy. Intravenous ICG imaging adds significant value to intraoperative decision-making. Anticipation of the complicated anatomy, a careful approach, and a highly skilled surgeon are required to successfully perform laparoscopic cholecystectomy in patients with liver cirrhosis. In conclusion, we suggest that it is technically feasible to perform a safe laparoscopic cholecystectomy in patients with MS and cirrhosis using additional ports and ICG mapping. We believe that this is the first published report of ICG-assisted laparoscopic cholecystectomy in type 1 MS with Child-Pugh A cirrhosis.

None.

No potential conflict of interest relevant to this article was reported.