|Year : 2016 | Volume
| Issue : 4 | Page : 330-333
Intra-cholecystic approach for laparoscopic management of Mirizzi's syndrome: A case series
Hirdaya H Nag, Vageesh Bettageri Gangadhara, Amit Dangi
Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
|Date of Submission||18-Jan-2015|
|Date of Acceptance||10-Nov-2015|
|Date of Web Publication||8-Sep-2016|
Hirdaya H Nag
Room No. 220, Academic Block, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic management of patients with Mirizzi's syndrome (MS) is not routinely recommended due to the high risk of iatrogenic complications. Patients and Methods: Intra-cholecystic (IC) or inside-gall bladder (GB) approach was used for laparoscopic management of 16 patients with MS at a tertiary care referral centre in North India from May 2010 to August 2014; a retrospective analysis of prospectively collected data was performed. Results: Mean age was 40.1 ± 14.7 years, the male-to-female ratio was 1:3, and 9 (56.25%) patients had type 1 MS (MS1) and 7 (43.75%) had type 2 MS (MS2) (McSherry's classification). The laparoscopic intra-cholecystic approach (LICA) was successful in 11 (68.75%) patients, whereas 5 patients (31.25%) required conversion to open method. Median blood loss was 100 mL (range: 50-400 mL), and median duration of surgery was 3.25 h (range: 2-7.5 h). No major complications were encountered except 1 patient (6.5%) who required re-operation for retained bile duct stones. The final histopathology report was benign in all the patients. No remote complications were noted during a mean follow-up of 20.18 months. Conclusion: LICA is a feasible and safe approach for selected patients with Mirizzi's syndrome; however, a low threshold for conversion is necessary to avoid iatrogenic complications.
Keywords: Cholecystectomy, complications, inside-gall bladder (GB) approach, intra-cholecystic (IC), IC approach, laparoscopic, laparoscopy, Mirizzi's syndrome (MS)
|How to cite this article:|
Nag HH, Gangadhara VB, Dangi A. Intra-cholecystic approach for laparoscopic management of Mirizzi's syndrome: A case series. J Min Access Surg 2016;12:330-3
| ¤ Introduction|| |
Mirizzi's syndrome (MS) is a type of obstructive jaundice resulting from the impaction of a sizable stone at gall bladder (GB) neck or inside cystic duct. It was first detected by Kehr (1905), and later on Pablo Mirizzi (1948) described this entity as a syndrome., MS is reported to occur in 0.06-5.7% of patients undergoing cholecystectomy for cholelithiasis., On the basis of endoscopic cholangiography findings, McSherry described two types of MS. Type 1 (MS1) is characterised by external compression of the common hepatic duct (CHD) by an impacted GB stone, and type 2 (MS2) is characterised by CHD obstruction resulting from inflammation, and direct fistulisation of the GB stone into the bile duct. Csendes et al. further classified MS2 into three subtypes and described that subtotal cholecystectomy (SC) with choledochoplasty is the most suitable procedure for the majority of patients with MS; however, depending upon the situation, other procedures are also required.
Laparoscopic cholecystectomy (LC) is the 'gold standard' for the management of patients with cholelithiasis. The reported incidence of bile duct injury (BDI) after LC for uncomplicated cholelithiasis is below 0.5%., The incidence of BDI after laparoscopic total/SC for MS ranges 2.5-22%., The high incidence of BDI in patients with MS is mainly due to technical difficulty created by an impacted stone, presence of inflammation and dense fibrosis. The inside-GB (intra-cholecystic) approach may be an alternative approach for LC in patients with severe fibrosis, including patients with MS. We hereby report our experience of 16 patients with MS who were managed by laparoscopic intra-cholecystic approach (LICA) or inside-GB approach.
| ¤ Patients and Methods|| |
LICA was used for the management of 16 patients with MS from May 2010 to August 2014 at a tertiary care centre in North India. All patients were operated upon by a single surgeon ( first author). Demographic characteristics, clinical features, investigations, operative details and postoperative complications were recorded prospectively. Preoperative work up included clinical physical examination, complete blood count (CBC), international normalised ratio (INR), renal function test (RFT), liver function test (LFT), ultrasound of the abdomen (US), magnetic resonance cholangiopancreaticography (MRCP), and endoscopic retrograde cholangiography (ERC) [Figure 1]. Endobiliary stent was placed in patients with cholangitis and/or in patients with incomplete clearance of common bile duct stones (CBDS). All patients with suspicion of gall bladder cancer (GBC) were advised contrast-enhanced computed tomography (CECT). If suspicion of GBC was verified by CECT, then these patients were not considered for LICA. In order to avoid iatrogenic complications, a low threshold for conversion to the open method was maintained. The duration of surgery was recorded in hours, blood loss was recorded in milliliters (mL) and McSherry's classification system was used to describe the types of MS. Postoperative complications were recorded as major if intervention or surgery was required, otherwise they were regarded as minor.
Patient position was supine, with legs apart; the camera assistant stood between the legs; the operating surgeon was on the left side of the patient, and in total five access ports were used. Maryland dissector, unipolar diathermy (L-hook), Harmonic scalpel (Ethicon Endosurgery, Johnson & Johnson, Cincinnati, USA), and ligaclips were used for dissection and haemostasis. An oblique cholecystostomy was made over GB neck and the liquid content of the GB was sucked out [Figure 2]a. The cholecystostomy was extended up to the anterolateral wall of the CBD if associated CBDS were present. Extraction of the stone was followed by a sudden gush of bile in patients with MS2, which was meticulously sucked out [Figure 2]b. The posterior (hepatic) wall of the GB was dissected away and transected at an appropriate distance from the junction of GB and CHD [Figure 3]a. Dissection of the hepatocystic triangle to identify the cystic artery was avoided, but it was ligated separately wherever possible [Clipped structure in [Figure 3]. GB flaps were approximated with interrupted Polyglactin (Vicryl) sutures (3-0, Ethicon, Johnson & Johnson, Aurangabad, India) [Figure 3]b. Intaoperative cholangiogram was performed in all the patients with choledochotomy. [BV Pulsera, Phillips, Holland]. The choledochotomy was closed over a 'T' tube and it was removed after 6 weeks. The check cholangiogram was always performed before the removal of 'T' tube.
|Figure 2: Showing extraction of impacted gall bladder stone through cholecystostomy (2a), and suction of 'gush of bile' after stone extraction (2b) |
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|Figure 3: Showing transaction of gall bladder (3a), and choledochoplsty (3b with inset)|
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Patients were followed up at every 3 months in the first year, every 6 months in the second year and yearly thereafter. Clinical evaluation and LFT were advised at every visit, and further investigations advised as indicated.
IBM SPSS version 20 (IBM, Chicago) was utilised for analysis; numerical data were represented as mean, median and range; categorical data were represented as percentages.
| ¤ Results|| |
The mean age was 40.1 ± 14.7 years, the female-to-male ratio was 3:1, preoperative diagnosis of MS was possible in 12 (75%), and the ratio of MS1 to MS2 was 9:7. Pain in upper abdomen was a universal symptom, and 6 (37.5%) patients had jaundice/cholangitis. Serum alkaline phosphatase (>117 U/L) was raised in 14 (87.5%) patients [Table 1]. LICA was successful in 11 (68.5%) patients, while 5 patients (31.5) required conversion; and the rate of conversion was not different between MS1 and MS2 [Table 2]. One patient (6.2%) required re-operation for a retained CBDS. Biopsy report of GB specimen was chronic cholecystitis in 15 (93.8%), and xanthogranulomatous cholecystitis in 1 (6.2%) patient. Mean follow-up was of 20.28 months, and there were no remote complications during this period [Table 2].
|Table 1: Demographic characteristics, clinical features and blood investigations|
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| ¤ Discussion|| |
The standard approach for LC involves extra-cholecystic (EC) dissection between GB neck and CHD to obtain a critical view of safety. In patients with MS, this particular surgical step is technically difficult and associated with a high risk of BDI. LICA avoids this step and reduces the risk of BDI; none of our patients sustained BDI, and similar results were reported by Hubert et al. Early cholecystostomy and removal of an impacted stone facilitates better identification of GB boundary from the inside and guides to a safe SC. Depending upon the situation, remnant GB (part attached to CHD) can be left open with obliteration of cystic duct (as described by Hubert et al.) or it can be closed as choledochoplasty; however, in patients with MS2, the latter is necessary. Precaution should be taken to avoid a large GB stump, which can predispose to recurrence of GB stones in future.
Preoperative diagnosis and proper surgical planning are important for the prevention of surgical complications in patients with MS., The diagnosis of MS should be suspected in every patient with impacted stone at GB neck, especially when it is associated with proximal dilatation of the bile duct and/or deranged LFT.,, Preoperative diagnosis of MS was available in 75% of patients in the present series, which helped in anticipation of problems and proper decision-making. LICA should be abandoned in all patients with preoperative or intraoperative suspicion of GBC because it may lead in dissemination of an otherwise resectable disease. The reported incidence of GBC in MS varies 5.3-28%;,, however, there were no patients with GBC in our series. This may be due to improved imaging technology and proper case selection; a recent series also reported a similar experience.
The conversion rate of the present series was lower than most of the earlier reports;,,, however, it was higher than mentioned by Chowbey et al. A low threshold for conversion is necessary to avoid iatrogenic complications and should not be considered as a failure. Spillage of GB contents and dissemination of an occult GBC is a real risk with LICA. The risk of infective complications and dissemination of occult GBC is also associated with SC by the open approach, but this risk is very high with LICA. Controlled evacuation of GB contents and use of an endobag may reduce the contact period of GB and its contents with the abdominal cavity, consequently reducing the risk of infective complications and dissemination of GBC. A patient with cholelithiasis needs careful evaluation to exclude GBC before laparoscopic surgery. A patient with even a remote suspicion of GBC should be treated as a patient with confirmed malignancy, and the appropriate approach should be adopted to avoid fatal complications and litigation. All the GB specimens should be sent for frozen biopsy and an appropriate surgical procedure should be added, if indicated.
The treatment of MS is mainly surgical, except in high-risk patients who can be treated with ERC with or without use lithotripsy. SC with or without CBD exploration is usually adequate for most of the patients with MS, but patients with friable bile duct and biliary stricture require bilioenteric anastomosis (Roux-en-Y). With the development of a minimally invasive (MI) approach, more complicated diseases (MS2 and/or cholecysto-enteric fistula) have been successfully treated with the MI approach. Recently, a combined endoscopic and robotic approach for the management of MS has been described.
| ¤ Conclusion|| |
Finally, we can conclude that LICA is a feasible and safe approach for the management of selected patients with MS; however, a low threshold for conversion is necessary to avoid iatrogenic complications.
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Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]