Mirizzi syndrome: An extra hazard for laparoscopic surgery

Background: Mirizzi Syndrome (MS) is an important but uncommon complication of gallstones characterized by narrowing of the common hepatic duct (CHD) due to mechanical compression or inflammation. This study aimed to assess the impact of preoperative and intraoperative diagnosis of MS on the performance, safety and efficacy of laparoscopic cholecystectomy. Methods: From a consecutive series of 1281 patients having surgery for gall bladder disease between 1990 and 1998, nine patients with MS were identified from a prospective database and their clinical progress examined. Results: Five out of the nine patients with MS presented with pain (2/5 were also jaundiced), and four presented with acute cholecystitis. Liver function tests were abnormal in all patients. Preoperative diagnosis of MS based on ultrasound was made in only two patients, and in a third on findings of a nasobiliary cholangiogram. In six patients, the diagnosis was intraoperative. In seven patients cholecystectomy was completed by laparoscopy. Two patients needed conversion to open cholecystectomy. In two patients the common bile duct was mistaken for the cystic duct and the error was recognized on relaxation of traction on the gall bladder in one, but in the other a duct injury occurred that was not recognized until the postoperative period. Conclusions: Preoperative diagnosis of MS is difficult, and a high index of suspicion is necessary to avoid serious complications. Once the diagnosis is known, successful laparoscopic management is possible but care should be taken to avoid duct injury.