What is the management approach for Mirizzi syndrome?

Management of Mirizzi Syndrome

Open cholecystectomy is the current standard treatment for Mirizzi syndrome, offering the safest approach with good short and long-term outcomes. 1

Preoperative Diagnosis and Planning

Diagnostic Approach

• Magnetic resonance cholangiopancreatography (MRCP) is the preferred diagnostic tool to identify the impacted gallstone causing extrinsic compression of the common hepatic duct and to classify the syndrome type 2, 3
• Endoscopic retrograde cholangiopancreatography (ERCP) with preoperative stent insertion in the common bile duct enables primary closure in cases requiring bile duct manipulation 4
• Ultrasound typically shows dilated intrahepatic and extrahepatic bile ducts with common bile duct dilation (often >15 mm) 5
• Preoperative diagnosis is crucial as it guides surgical planning and improves outcomes, though a significant proportion of cases are still diagnosed intraoperatively 2

Classification Matters for Surgical Planning

• The Csendes classification system guides treatment decisions based on the presence and severity of cholecystobiliary fistula 2
• Type I (35% of cases): External compression without fistula - simple cholecystectomy usually sufficient 6
• Type II (53% of cases): Cholecystobiliary fistula involving <1/3 of bile duct circumference - may require choledochotomy with T-tube insertion 6
• Type III (12% of cases): Fistula involving >2/3 of bile duct - requires Roux-en-Y hepaticojejunostomy 6

Surgical Management Algorithm

Primary Approach

• Open cholecystectomy remains the gold standard due to the high risk of bile duct injury with laparoscopic techniques in the setting of dense adhesions and distorted anatomy at Calot's triangle 1, 2
• Laparoscopic approach is feasible only in specialized centers with well-trained surgeons, particularly for less severe stages (Type I), with conversion rates of approximately 22% 4, 2

Intraoperative Strategy

• Subtotal cholecystectomy is the safest approach when total cholecystectomy cannot be performed safely due to unclear anatomy or dense fibrosis 4, 2, 3
• Intraoperative cholangiography should be performed when biliary anatomy is unclear 1
• Convert to open surgery immediately when the anatomy cannot be safely managed laparoscopically - this is critical to prevent bile duct injury 1
• Anterograde cholecystectomy carries high risk of damaging branches of the right hepatic artery and bile duct when the gallbladder infundibulum is adhered to the right hepatic hilum 3

Type-Specific Procedures

• Type I: Cholecystectomy alone in 83% of cases; some require T-tube insertion 6
• Type II: Cholecystectomy with choledochotomy and T-tube insertion in 78% of cases; remainder require bilioenteric anastomosis 6
• Type III: Cholecystectomy with Roux-en-Y hepaticojejunostomy is the appropriate procedure with good outcomes 6

Critical Pitfalls to Avoid

Anatomical Hazards

• Branches of the right hepatic artery are damaged more easily than the bile duct when the gallbladder infundibulum is adhered to the right hepatic hilum - this is a hidden pitfall 3
• The right portal vein branches may also cling to the gallbladder infundibulum in severe inflammation 3
• Dense adhesions and distorted anatomy at Calot's triangle significantly increase bile duct injury risk 2

Preoperative Considerations

• Complete stone clearance should be achieved, ideally with ERCP before surgery 4
• Screen for concomitant gallbladder carcinoma, which has higher association with Mirizzi syndrome 3
• Deferring ERCP may be appropriate when MRCP clearly demonstrates Mirizzi syndrome anatomy 5

Expected Outcomes

• Morbidity rate of approximately 5.8% with appropriate surgical approach 6
• No perioperative mortality reported in experienced centers with proper preoperative planning 4, 6
• Hospital stay may be prolonged if conversion to open surgery is required or if postoperative complications occur 5