Journal of Gastrointestinal Surgery

, Volume 21, Issue 3, pp 583–589 | Cite as

Performing the Difficult Cholecystectomy Using Combined Endoscopic and Robotic Techniques: How I Do It

  • Deepa MaggeEmail author
  • Jennifer Steve
  • Stephanie Novak
  • Adam Slivka
  • Mellissa Hogg
  • Amer Zureikat
  • Herbert J. ZehIII
How I do it


Laparoscopic cholecystectomy is the standard of care for cholelithiasis as well as cholecystitis. However, in the setting of Mirizzi syndrome or gangrenous cholecystitis where the critical view cannot be ascertained, subtotal cholecystectomy may be necessary. Using the robot-assisted approach, difficult cholecystectomies can be performed upfront without need for partial cholecystectomy. Even in the setting of Mirizzi syndrome where severe scarring and fibrosis are evident, definitive cholecystectomy and takedown of the cholechystocholedochal fistula can be performed in a safe and feasible fashion following successful endoscopic common bile duct stent placement. The purposes of this report are to review the history of Mirizzi syndrome as well as its traditional and novel treatment techniques and highlight technical pearls of the robotic approach to this diagnosis.


Cholecystectomy Robot-assisted Mirizzi syndrome Cholecystocholedochal fistula 

Supplementary material

Video 1

(MP4 161384 kb)


  1. 1.
    Bornman PC, Terblanche J. Sub-total cholecystectomy: for the difficult gall bladder in portal hypertension and cholecystitis. Surgery 1985;98(1):1–6.PubMedGoogle Scholar
  2. 2.
    Csendes A, Díaz JC, Burdiles P, Maluenda F, Nava O. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 1989;76(11):1139–1143.CrossRefPubMedGoogle Scholar
  3. 3.
    Kumar A, Senthil G, Prakash A et al. Mirizzi Syndrome: Lessons learnt from 169 patients at a single center. Korean J Hepatobiliary Pancreat Surg. 2016 Feb. 20(1): 17–22.Google Scholar
  4. 4.
    Douglas PR, Ham JM. Partial cholecystectomy. Aust N Z J Surg 1990;60(8):595–597.CrossRefPubMedGoogle Scholar
  5. 5.
    Cottier DJ, McKay C, Anderson JR. Subtotal cholecystectomy. Br J Surg 1991;78(11):1326–1328.CrossRefPubMedGoogle Scholar
  6. 6.
    Ibrarullah MD, Kacker LK, Sikora SS, Saxena R, Kapoor VK, Kaushik SP. Partial cholecystectomy—safe and effective. HPB Surg 1993;7(1):61–65.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Johnson LW, Sehon JK, Lee WC, Zibari GB, McDonald JC. Mirizzi Syndrome: experience from a multi-institutional review. Am Surg. 2001; 67(1):11–14.PubMedGoogle Scholar
  8. 8.
    Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World J Surg. 2008 Oct;32(10):2237–43.Google Scholar
  9. 9.
    Petricevic PB, Kontic OM, Petricevic MZ, Kontic MM, Smit G. Mirizzi syndrome—two case reports and a short review of the literature. Int Surg. 2011; 96(3): 228–232.CrossRefPubMedGoogle Scholar
  10. 10.
    Waisberg J, Corona A, de Abreu IW, Farah JF, Lupinacci RA, Goffi FS. Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management. Arg Gastroenterol. 2005; 42(1):13–18.CrossRefGoogle Scholar
  11. 11.
    Johnson AB, Fink AS. Alternative methods for management of the complicated gallbladder. Semin Laparosc Surg 1998;5(2):115–120.PubMedGoogle Scholar
  12. 12.
    Mack MJ. Minimally invasive and robotic surgery. JAMA. 2001; 285: 568–572.CrossRefPubMedGoogle Scholar
  13. 13.
    Cadiere GB, Himpens J, Germay O, et al. Feasibility of robotic laparoscopic surgery: 146 cases. World J Surg 2001; 25: 1467–1477.PubMedGoogle Scholar
  14. 14.
    Chowbey PK, Bandyopadhyay SK, Sharma A, Khullar R, Soni V, Baijal M. Laparoscopic reintervention for residual gallstone disease. Surg Laparosc Endosc Percutan Tech 2003;13(1):31–35.CrossRefPubMedGoogle Scholar
  15. 15.
    Piccinni G, Sciusco A, De Luca GM et al. Minimally Invasive Treatment of Mirizzi Syndrome: Is there a safe way? Report of a case series. Ann Hepatol 2014; 13(5):558–564.PubMedGoogle Scholar
  16. 16.
    Janes S, Berry L, Dijkstra B. Management of post cholecystectomy Mirizzi Syndrome. J Min Access Surg 2005;1(1):34–36.CrossRefGoogle Scholar
  17. 17.
    Jayant M, Kaushik R. Presentation and management of gallbladder remnant after partial cholecystectomy. Trop Gastroenterol. 2013 Apr-Jun;34(2):99–103.Google Scholar
  18. 18.
    Ji W, Li LT, Li JS. Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int. 2006;5(4):584–589.PubMedGoogle Scholar
  19. 19.
    Kwon AH, Inui H. Preoperative diagnosis and efficacy of laparoscopic procedures in the treatment of Mirizzi syndrome. J Am Coll Surg 2007;204(3):409–415.CrossRefPubMedGoogle Scholar
  20. 20.
    Kamalesh NP, Prakash K, Pramil K et al. Laparoscopic approach is safe and effective in the management of Mirizzi Syndrome. J Minim Access Surg. 2014;11(4): 246–250.CrossRefGoogle Scholar
  21. 21.
    Antoniou SA, Antoniou GA, Makridis C. Laparoscopic treatment of Mirizzi syndrome: a systematic review..Surg Endosc. 2010 Jan;24(1):33–9.Google Scholar
  22. 22.
    Lee KF, Lee SC, Leong HT. Laparoscopic resection of gallbladder remnant: case report. Ann Coll Surg HK 2002;6:58–60.CrossRefGoogle Scholar
  23. 23.
    Lee KF, Chong CN, Ma KW et al. A Minimally Invasive strategy for Mirizzi Syndrome: the combined endoscopic and robotic approach. Surg Endosc 2014; 28(9):2690–2694.CrossRefPubMedGoogle Scholar
  24. 24.
    Tung KL, Tang CN, Lai EC et al. Robot-assisted laparoscopic approach of management for Mirizzi syndrome. Surg Laparosc Endosc Percutan Tech. 2013 Feb;23(1):17–21.Google Scholar
  25. 25.
    Rieger R, Wayand W. Gallbladder remnant after laparoscopic cholecystectomy. Surg Endosc 1995;9(7):844.CrossRefPubMedGoogle Scholar
  26. 26.
    Gurel M, Sare M, Gurer S, Hilmioglu F. Laparoscopic removal of a gallbladder remnant. Surg Laparosc Endosc 1995;5(5):410–411.PubMedGoogle Scholar
  27. 27.
    Kohn, G. P. and Martinie, J. B. (2009), Laparoscopic robot-assisted completion cholecystectomy: a report of three cases. Int. J. Med. Robotics Comput. Assist. Surg., 5: 406–409.CrossRefGoogle Scholar
  28. 28.
    Ransom KJ. Laparoscopic management of acute cholecystitis with subtotal cholecystectomy. Am Surg 1998;64(10):955–957.PubMedGoogle Scholar
  29. 29.
    Clemente G, Giuliante F, Cadeddu F, Nuzzo G. Laparoscopic removal of gallbladder remnant and long cystic stump. Endoscopy 2001;33(9):814–815PubMedGoogle Scholar
  30. 30.
    Schofer JM. Biliary causes of postcholecystectomy syndrome. J Emerg Med 2008.Google Scholar
  31. 31.
    Kim JY, Kim KW, Ahn CS, Hwang S, Lee YJ, Shin YM, Lee MG. Spectrum of biliary and nonbiliary complications after laparoscopic cholecystectomy: radiologic findings. AJR Am J Roentgenol 2008;191(3):783–789.CrossRefPubMedGoogle Scholar
  32. 32.
    Vyas FL, Nayak S, Perakath B, Pradhan NR. Gallbladder remnant and cystic duct stump calculus as a cause of postcholecystectomy syndrome. Trop Gastroenterol 2005;26(3):159–160.PubMedGoogle Scholar
  33. 33.
    Tiwisina T. “On the subject of “gallbladder regeneration”, bile-hepatic duct diverticulum and pseudodiverticulum. Zentralbl Chir 1966;91(1):1–7.PubMedGoogle Scholar
  34. 34.
    Blackard WG Jr, Baron TH. Leaking gallbladder remnant with cholelithiasis complicating laparoscopic cholecystectomy. South Med J 1995;88(11):1166–1168.CrossRefPubMedGoogle Scholar
  35. 35.
    Cohen SA, Attiyeh FF, Kasmin FE, Siegel JH. Persistence of the gallbladder following laparoscopic cholecystectomy: a case report. Endoscopy 1995;27(4):334–336.CrossRefPubMedGoogle Scholar
  36. 36.
    Walsh RM, Chung RS, Grundfest-Broniatowski S. Incomplete excision of the gallbladder during laparoscopic cholecystectomy. Surg Endosc 1995;9(1):67–70.CrossRefPubMedGoogle Scholar
  37. 37.
    Walsh RM, Ponsky JL, Dumot J. Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain. Surg Endosc 2002;16(6):981–984.CrossRefPubMedGoogle Scholar
  38. 38.
    Daly TD, Martin CJ, Cox MR. Residual gallbladder and cystic duct stones after laparoscopic cholecystectomy. ANZ J Surg 2002;72(5):375–377.CrossRefPubMedGoogle Scholar
  39. 39.
    Katsohis C, Prousalidis J, Tzardinoglou E, Michalopoulos A, Fahandidis E, Apostolidis S, Aletras H. Subtotal cholecystectomy. HPB Surg 1996;9(3):133–136.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Glenn F, McSherry CK. Secondary abdominal operations for symptoms following biliary tract surgery. Surg Gynecol Obstet 1965;121(5):979–988.PubMedGoogle Scholar
  41. 41.
    Rogy MA, Függer R, Herbst F, Schulz F. Reoperation after cholecystectomy. The role of the cystic duct stump. HPB Surg 1991;4(2):129–134. discussion 134–135.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Lasson A. The postcholecystectomy syndrome: diagnostic and therapeutic strategy. Scand J Gastroenterol 1987;22(8):897–902.CrossRefPubMedGoogle Scholar
  43. 43.
    Tsoraides SS, Cha AI, Crawford D. Postcholecystectomy biliary symptoms. J Surg Educ 2007;64(4):228–233.CrossRefPubMedGoogle Scholar
  44. 44.
    Hellmig S, Katsoulis S, Fölsch U. Symptomatic cholecystolithiasis after laparoscopic cholecystectomy. Surg Endosc 2004;18(2):347.PubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2016

Authors and Affiliations

  1. 1.Division of GI Surgical OncologyUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.Division of GI Surgical OncologyUniversity of Pittsburgh Medical CenterPittsburghUSA

Personalised recommendations