Surgical Endoscopy

, Volume 30, Issue 12, pp 5635–5646 | Cite as

Laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II: a simplified standardized technique

  • Shu-Hung Chuang
  • Meng-Ching Yeh
  • Chien-Jen ChangEmail author
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Laparoscopic treatment is a viable option for Mirizzi syndrome (MS) type I, but it is not recommended for MS type II (McSherry classification). We introduce laparoscopic transfistulous bile duct exploration (LTBDE) as a simplified standardized technique for MS type II.


Eleven consecutive LTBDEs performed by a surgeon for MS type II were analyzed retrospectively, including three successful single-incision LTBDEs (SILTBDEs). Transfistulous stone removal followed by primary closure of gallbladder remnant and partial cholecystectomy was performed. An additional choledochotomy was required in one patient.


Preoperative endoscopic retrograde cholangiopancreatography and operative findings confirmed the diagnosis of MS in five and five patients, respectively. Preoperative ultrasound implied the remaining diagnosis. The operative time was 270.5 ± 65.5 min. The stone clearance rate was 100 %. The postoperative length of hospital stay was 5.1 ± 2.2 days. There was no open conversion. Overall complications comprised two postoperative transient hyperamylasemia (18.2 %) and one superficial wound infection (9.1 %). Compared with the other group of 92 patients who underwent laparoscopic bile duct exploration, the MS type II group had a significantly younger age, a higher jaundice rate, a lower single-incision laparoscopic approach rate, a lower choledochotomy rate, longer operative time, a lower postoperative pethidine dose, and a longer total length of hospital stay. The average follow-up period was 12.1 months.


LTBDE is safe and efficacious for MS type II including Csendes type IV. A high suspicion of MS is critical. SILTBDE is feasible in selected cases. Long-term follow-up is mandatory.


Choledochotomy Cystocholedochal Infundibulotomy Laparoscopic bile duct exploration Mirizzi syndrome Single-incision laparoscopic surgery Transfistulous 



We gratefully acknowledge the obligatory works of Ms. Yi-Chun Liao and Ms. Pei-Yi Wang in assisting with the data collection.

Compliance with ethical standards


Drs. Shu-Hung Chuang, Meng-Ching Yeh, and Chien-Jen Chang have no conflicts of interest or financial ties to disclose.

Supplementary material

Video 1

Standard four-incision laparoscopic transfistulous bile duct exploration in patient No. 5. The diagnosis of Csendes type IV was confirmed by intraoperative findings and completion cholangiogram. A 2-cm stone impacted at cystocholedochal junction was crushed and extracted with a grasper (WMV 209529 kb)

Video 2

Single-incision laparoscopic transfistulous bile duct exploration and partial cholecystectomy in patient No. 9. Cystic duct anomaly of parallel course with low and anterior insertion and the diagnosis of Csendes type III were identified by diagnostic and completion cholangiograms. A 0.8-cm stone impacted at cystocholedochal junction was loosened and extracted with a basket (WMV 125451 kb)


  1. 1.
    Beltrán MA (2012) Mirizzi syndrome: history, current knowledge and proposal of a simplified classification. World J Gastroenterol 18:4639–4650CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Lai EC, Lau WY (2006) Mirizzi syndrome: history, present and future development. ANZ J Surg 76:251–257CrossRefPubMedGoogle Scholar
  3. 3.
    Erben Y, Benavente-Chenhalls LA, Donohue JM, Que FG, Kendrick ML, Reid-Lombardo KM, Farnell MB, Nagorney DM (2011) Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo clinic experience. J Am Coll Surg 213:114–119CrossRefPubMedGoogle Scholar
  4. 4.
    Kwon AH, Inui H (2007) Preoperative diagnosis and efficacy of laparoscopic procedures in the treatment of Mirizzi syndrome. J Am Coll Surg 204:409–415CrossRefPubMedGoogle Scholar
  5. 5.
    Gomez D, Rahman SH, Toogood GJ, Prasad KR, Lodge JP, Guillou PJ, Menon KV (2006) Mirizzi’s syndrome—results from a large western experience. HPB (Oxf.) 8:474–479CrossRefGoogle Scholar
  6. 6.
    Rohatgi A, Singh KK (2006) Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy. Surg Endosc 20:1477–1481CrossRefPubMedGoogle Scholar
  7. 7.
    Yeh CN, Jan YY, Chen MF (2003) Laparoscopic treatment for Mirizzi syndrome. Surg Endosc 17:1573–1578CrossRefPubMedGoogle Scholar
  8. 8.
    Schäfer M, Schneiter R, Krähenbühl L (2003) Incidence and management of Mirizzi syndrome during laparoscopic cholecystectomy. Surg Endosc 17:1186–1190CrossRefPubMedGoogle Scholar
  9. 9.
    Chowbey PK, Sharma A, Mann V, Khullar R, Baijal M, Vashistha A (2000) The management of Mirizzi syndrome in the laparoscopic era. Surg Laparosc Endosc Percutan Tech 10:11–14CrossRefPubMedGoogle Scholar
  10. 10.
    Hubert C, Annet L, van Beers BE, Gigot JF (2010) The “inside approach of the gallbladder” is an alternative to the classic Calot’s triangle dissection for a safe operation in severe cholecystitis. Surg Endosc 24:2626–2632CrossRefPubMedGoogle Scholar
  11. 11.
    Antoniou SA, Antoniou GA, Makridis C (2010) Laparoscopic treatment of Mirizzi syndrome: a systematic review. Surg Endosc 24:33–39CrossRefPubMedGoogle Scholar
  12. 12.
    Csendes A, Díaz JC, Burdiles P, Maluenda F, Nava O (1989) Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 76:1139–1143CrossRefPubMedGoogle Scholar
  13. 13.
    McSherry CK, Ferstenberg H, Virshup M (1982) The Mirizzi syndrome: suggested classification and surgical therapy. Surg Gastroenterol 1:219–225Google Scholar
  14. 14.
    Beltran MA, Csendes A, Cruces KS (2008) The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World J Surg 32:2237–2243CrossRefPubMedGoogle Scholar
  15. 15.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Chuang SH, Chen PH, Chang CM, Tsai YF, Lin CS (2014) Single-incision laparoscopic common bile duct exploration with conventional instruments: an innovative technique and a comparative study. J Gastrointest Surg 18:737–743CrossRefPubMedGoogle Scholar
  17. 17.
    Vezakis A, Davides D, Birbas K, Ammori BJ, Larvin M, McMahon MJ (2000) Laparoscopic treatment of Mirizzi syndrome. Surg Laparosc Endosc Percutan Tech 10:15–18CrossRefPubMedGoogle Scholar
  18. 18.
    Yip AW, Chow WC, Chan J, Lam KH (1992) Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management. Surgery 111:335–338PubMedGoogle Scholar
  19. 19.
    Bower TC, Nagorney DM (1988) Mirizzi syndrome. HPB Surg 1:67–74CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Waisberg J, Corona A, de Abreu IW, Farah JF, Lupinacci RA, Goffi FS (2005) Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management. Arq Gastroenterol 42:13–18CrossRefPubMedGoogle Scholar
  21. 21.
    Lin CL, Changchien CS, Chen YS (1997) Mirizzi’s syndrome with a high CA19-9 level mimicking cholangiocarcinoma. Am J Gastroenterol 92:2309–2310PubMedGoogle Scholar
  22. 22.
    Baer HU, Matthews JB, Schweizer WP, Gertsch P, Blumgart LH (1990) Management of the Mirizzi syndrome and the surgical implication of cholecystocholedochal fistula. Br J Surg 77:743–745CrossRefPubMedGoogle Scholar
  23. 23.
    Yin Z, Xu K, Sun J, Zhang J, Xiao Z, Wang J, Niu H, Zhao Q, Lin S, Li Y (2013) Is the end of the T-tube drainage era in laparoscopic choledochotomy for common bile duct stones is coming? A systematic review and meta-analysis. Ann Surg 257:54–66CrossRefPubMedGoogle Scholar
  24. 24.
    Wu X, Yang Y, Dong P, Gu J, Lu J, Li M, Mu J, Wu W, Yang J, Zhang L, Ding Q, Liu Y (2012) Primary closure versus T-tube drainage in laparoscopic common bile duct exploration: a meta-analysis of randomized clinical trials. Langenbecks Arch Surg 397:909–916CrossRefPubMedGoogle Scholar
  25. 25.
    Krähenbühl L, Moser JJ, Redaelli C, Seiler Ch, Maurer Ch, Baer HU (1997) A standardized surgical approach for the treatment of Mirizzi syndrome. Dig Surg 14:272–276CrossRefGoogle Scholar
  26. 26.
    Kim DC, Moon JH, Choi HJ, Choi MH, Lee TH, Cha SW (2014) Successful endoscopic treatment for Mirizzi syndrome type II under direct peroral cholangioscopy using an ultraslim upper endoscope. Endoscopy 46:E103–E104CrossRefPubMedGoogle Scholar
  27. 27.
    Issa H, Bseiso B, Al-Salem AH (2011) Successful laser lithotripsy using peroral SpyGlass cholangioscopy in a patient with Mirizzi syndrome. Endoscopy 43:E166–E167CrossRefPubMedGoogle Scholar
  28. 28.
    Tsuyuguchi T, Sakai Y, Sugiyama H, Ishihara T, Yokosuka O (2011) Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: an analysis of risk factors predicting stone recurrence. Surg Endosc 25:2179–2185CrossRefPubMedGoogle Scholar
  29. 29.
    Shah OJ, Dar MA, Wani MA, Wani NA (2001) Management of Mirizzi syndrome: a new surgical approach. ANZ J Surg 71:423–427CrossRefPubMedGoogle Scholar
  30. 30.
    Montefusco P, Spier N, Geiss AC (1983) Another facet of Mirizzi’s syndrome. Arch Surg 118:1221–1223CrossRefPubMedGoogle Scholar
  31. 31.
    Lubbers EJ (1983) Mirizzi syndrome. World J Surg 7:780–785CrossRefPubMedGoogle Scholar
  32. 32.
    Chuang SH, Chen PH, Chang CM, Lin CS (2013) Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis. World J Gastroenterol 19:7743–7750CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Chuang SH, Yang WJ, Chang CM, Lin CS, Yeh MC (2015) Is routine single-incision laparoscopic cholecystectomy feasible? A retrospective observational study. Am J Surg 210:315–321CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Shu-Hung Chuang
    • 1
    • 2
  • Meng-Ching Yeh
    • 1
  • Chien-Jen Chang
    • 1
    Email author
  1. 1.Department of SurgeryMacKay Memorial Hospital, Hsin-Chu BranchHsin-ChuTaiwan
  2. 2.Department of Healthcare ManagementYuanpei University of Medical TechnologyHsin-ChuTaiwan

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