Mirizzi syndrome: Problems and strategies.

Mirizzi syndrome is a serious complication of gallstone disease. It is caused by the impacted stones in the gallbladder neck or cystic duct. One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot's triangle. In our clinical practice, bile duct, branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum. The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct, all of which are hidden pitfalls for surgeons. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferable tools for the diagnosis of Mirizzi syndrome. Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum. Subtotal cholecystectomy is an easy, safe and definitive approach to Mirizzi syndrome. When combined with the application of ERCP, a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe. The objective of this review was to highlight its existing problems: (1) low preoperative diagnostic rate, (2) easy to damage bile duct and branches of right hepatic artery, and (3) high concomitant gallbladder carcinoma. Meanwhile, the review aimed to discuss the possible therapeutic strategies: (1) to enhance its preoperative recognition by imaging findings, and (2) to avoid potential pitfalls during surgery.

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

[Endoscopic treatment of Mirizzi syndrome]. / Endoskopicheskoe lechenie sindroma Mirizzi.

Mirizzi syndrome is a complication of cholelithiasis occurring in 0.25-6% of cases [1]. Clinical pattern includes jaundice due to prolapse of a large calculus into the common bile duct following cholecystocholedochal fistula. Ultrasound, CT, MRI, MRCP data, as well as some pathognomonic signs provide preoperative diagnostics of Mirizzi syndrome. In most cases, treatment of this syndrome requires open surgery. We report successful endoscopic treatment of a patient with long-standing bile stone disease complicated by Mirizzi syndrome. Postoperative complications of surgery performed in acute period of disease and further staged treatment using retrograde access are illustrated. Endoscopic treatment demonstrated minimally invasive management of disease presenting diagnostic and technical difficulties.

Single-incision versus four-incision laparoscopic transfistulous bile duct exploration for Mirizzi syndrome type II.

BACKGROUND: We developed laparoscopic transfistulous bile duct exploration (LTBDE) for Mirizzi syndrome (MS) McSherry type II in September 2011. Then, single-incision LTBDE (SILTBDE) was adopted as a preferred technique since August 2013. This retrospective study aims to analyze the outcome of LTBDE in 7.7 years and to compare SILTBDE with four-incision LTBDE (4ILTBDE). METHODS: Seventeen consecutive patients underwent LTBDE for MS McSherry type II from September 2011 to May 2019. Transfistulous removal of the impacted stone(s), choledochoscopic bile duct exploration, and primary closure of the gallbladder remnant were performed without biliary drainage. RESULTS: The sex ratio is 12:5 (male: female) with an average age of 39.4 ± 10.3 (24-56) years. Ten patients (58.8%) had their diagnoses of MS established by preoperative imaging. According to the Csendes classification, three type II (17.6%), nine type III (52.9%), and five type IV (29.4%) were identified. The operative time was 264.8 ± 60.3 min (156-358 min). The stone clearance rate was 100%. The postoperative hospital stay was 4.7 ± 1.9 (2-10) days. No procedure was converted to an open operation. Two postoperative transient hyperamylasemia (11.8%) and one superficial wound infection (5.9%) occurred and all recovered well under conservative treatment (Clavien-Dindo grade I). During an average 2.2-year follow-up period, no biliary stricture or stone recurrence occurred. No significant difference exists between the SILTBDE and 4ILTBDE groups. Nevertheless, an insignificant trend of shorter postoperative hospital stay was observed in the former. A diagnosis of MS Csendes type IV implicates prolonged total and postoperative hospital stays (p < 0.01). CONCLUSIONS: LTBDE is safe and efficacious for MS McSherry type II. It provides a simple solution for various types of MS and avoids undesirable complications following bilioenteric anastomosis. SILTBDE is comparable to 4ILTBDE for selected patients. Patients with MS Csendes type IV need more time to recover after surgery.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report.

BACKGROUND: Iatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy. CASE PRESENTATION: We report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later. CONCLUSIONS: Even with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Cystic duct stones in postcholecystectomy Mirizzi syndrome - A novel endoscopic treatment.

Mirizzi syndrome is a rare type of cholelithiasis, and the main treatment is still surgery. The development of endoscopic technology has made surgeons more active in the management of rare diseases of the biliary tract and pancreas. Here we report that our center applied the new endoscopic method to treat a Mirizzi patient with residual cystic neck duct stones after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy in a type Va Mirizzi syndrome patient.

Mirizzi syndrome is a rare syndrome, caused by the compression of gall stones which may result in CBD obstruction or fistula formation. It may sometimes present without any prior symptoms. It has been classified into five types by Csendes. Usually open surgical approach is recommended for the condition, especially for Types III-V. We present the case of a patient who presented with right hypochondrial pain and was intra-operatively discovered to have type Va Mirrizi syndrome and was managed successfully laparoscopically.

One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units.

BACKGROUND: To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks. METHODS: Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones. RESULTS: 38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals. CONCLUSION: Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality.

Emergency surgery for hemobilia due to hepatic artery pseudoaneurysm rupture complicated by Mirizzi syndrome type II: a case report.

BACKGROUND: Hemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required. CASE PRESENTATION: A 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks. CONCLUSIONS: We experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required.

Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review.

BACKGROUND: Laparoscopic approaches for the management of Mirizzi syndrome (MS) are controversial and challenging procedures for high conversion rate. This review aims at evaluating their safety and feasibility. METHODS: We reviewed studies related to the laparoscopic approaches for the management of MS with detailed data of articles from January 2009 to December 2019 found in PubMed. RESULTS: From 63 articles, we reviewed 17 articles detailing laparoscopic approaches for MS. There were 857 patients with MS; 432 of which were identified from 73,842 patients underwent cholecystectomy. Laparoscopic approaches were attempted in 440 patients and were successful in 290. The conversion rate was 34.09%. Various methods including laparoscopic cholecystectomy, laparoscopic subtotal cholecystectomy, laparoscopic common bile duct exploration (LCBDE) and (LTCBDE) were performed. The preoperative diagnosis of MS was made in 338 of 500 patients (67.60%). The mean operating time ranged from 49.7 ± 27.5 min to 270.5 ± 65.5 min, and the mean intraoperative bleeding varied from 21.1 ± 15.9 ml to 162.81 ± 40.83 ml. The mean hospital stay varied from 4.5 ± 3.7 to 7.21 ± 1.61 days. Postoperative complications occurred in 27 patients. CONCLUSIONS: Various laparoscopic approaches are safe and feasible for the treatment of MS in the hands of experienced laparoscopic surgeons, especially for type I and II of Csendes classification. Definitive preoperative diagnosis and earlier management are essential.

Laparoscopic management of type II Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently open cholecystectomy was the standard of care for type II Mirizzi syndrome (McSherry classification). The objective of this study was to assess the incidence and management of type II Mirizzi syndrome in patients with proven or suspected choledocholithiasis undergoing laparoscopic common bile duct (CBD) exploration and present our experience in the laparoscopic management of this rare condition over the last 21 years. METHODS: Prospective data collection of eleven cases of type II Mirizzi syndrome amongst a series of 425 laparoscopic bile duct explorations was performed between 1998 and 2019. Demographic, clinical, diagnostic, intra-operative, and post-operative data were recorded. RESULTS: The incidence of type II Mirizzi syndrome was 2.6% in 425 laparoscopic CBD explorations. All operations were completed laparoscopically with closure of the defect over a decompressed CBD (T-tube n = 3, antegrade stent n = 5, transcystic drain n = 2), and in one case a non-drained duct was closed with Endoloop. Stone clearance rate was 100% (11 cases). In two patients the transinfundibular approach was used in conjunction with holmium laser lithotripsy to enable choledochoscopy and successful stone clearance. Three patients were complicated in the post-operative period with bile leak (n = 2) and lower respiratory tract infection (n = 1). An incidental gallbladder carcinoma was found in one patient. CONCLUSION: Laparoscopic management of type II Mirizzi syndrome is feasible and safe when performed by experienced laparoscopic foregut surgeons. Laparoscopy and choledochoscopy can be combined with novel approaches and techniques to increase the likelihood of treatment success.

Critical Appraisal of the Impact of the Systematic Adoption of Advanced Minimally Invasive Hepatobiliary and Pancreatic Surgery on the Surgical Management of Mirizzi Syndrome.

BACKGROUND: Minimally invasive surgery (MIS) for Mirizzi syndrome (MS) remains a technically challenging procedure with a high open conversion rate. We critically evaluated the impact of the systematic adoption of MI-HBP surgery on the surgical outcomes of MS. METHODS: Ninety-five patients who underwent surgery for MS were retrospectively reviewed. Systematic adoption of advanced MI-HBP surgery started in 2012. The cohort was classified into a preadoption (2002-2012) (Era 1, n = 58) and post-adoption (2013-2017) (Era 2, n = 37). Furthermore, Era 2 was divided into a cohort operated by advanced minimally invasive surgeons (AMIS) (Era 2 AMIS, n = 19) and those by other surgeons (Era 2 others, n = 19). RESULTS: Comparison between Era 2 and Era 1 demonstrated a significant increase in the frequency of MIS attempted (89% vs 33%, p < 0.01), increase in the use of choledochoplasty (24% vs 2%, p < 0.01), increase operation time (180 min vs 150 min, p = 0.03) and significantly lower open conversion rate (24% vs 58%, p < 0.01). Comparison between Era 2 AMIS and Era 2 others demonstrated a significantly greater adoption of MIS (100% vs 78%, p = 0.046) with lower open conversion rate (5% vs 50%, p = 0.005). Comparison between all attempted MIS cases with open procedures demonstrated a significantly higher proportion of subtotal cholecystectomies performed (40% vs 23%, p = 0.04), choledochoplasty (17% vs 2%, p = 0.04) and shorter hospital stay (4 days vs 9 days, p < 0.01). CONCLUSIONS: Systematic adoption of advanced MI-HBP surgery allowed surgeons to perform MIS for MS more frequently and with a significantly lower open conversion rate. Patients who underwent successful MIS had the shortest hospital stay compared to patients who underwent open surgery or required open conversion.

A Retrospective Review of the Diagnostic and Management Challenges of Mirizzi Syndrome at the Singapore General Hospital.

BACKGROUND: Mirizzi syndrome (MS) occurs when gallstone impaction in Hartmann's pouch results in extrinsic obstruction of the common bile duct, and fistulation may occur. METHODS: We retrospectively reviewed electronic records of patients surgically treated for MS from November 2001 to June 2012. Patient presentations, diagnostic methods, treatments and complications were recorded. RESULTS: Sixty-four patients were grouped according to a classification proposed by Beltran et al. [World J Surg 2008; 32: 2237-2243]. Forty-three (66.2%), 18 (27.7%) and 3 (4.6%) patients were classified as types I, II, and III respectively. Magnetic-resonance-cholangiopancreaticography was the most sensitive imaging modality, suggesting MS in 24 (88.9%), followed by CT scan (40%) and ultrasonography (11.4%). Forty-four underwent Endoscopic-retrograde-cholangiopancreaticography and 29 (65.9%) suggested the presence of MS. MS was accurately diagnosed pre-operatively in 48 (73.8%) patients. In type I, 40 (93.0%) patients underwent cholecystectomy, while 3 required hepaticojejunostomy. In type II, 12 (66.7%) underwent cholecystectomy and 5 (27.8%) required hepatico-enteric anastomosis. In type III, 1 underwent cholecystectomy and 2 (66.7%) required hepatico-enteric anastomosis. Laparoscopic cholecystectomy was attempted in 20 (30.8%) patients and 13 (65.0%) required conversion. Twenty-nine (44.6%) underwent intra-operative-cholangioscopy, 30 (46.2%) underwent intra-operative-cholangiogram and 41 (63.1%) underwent intra-operative T-tube placement. Six (9.2%) experienced intra-operative complications, 12 (18.5%) experienced post-operative complications and 10 (15.4%) experienced late complications. CONCLUSION: MS is a challenging condition and multimodal diagnostic approach has the greatest yield in achieving accurate pre-operative diagnosis. If suspicion is high, a trial of laparoscopic dissection with low threshold for open conversion is recommended.

Complicated gallstone disease: diagnosis and management of Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome (MS) is characterized by an obstruction of the proximal bile duct due to extrinsic compression by either an impacted stone in the gallbladder neck or local inflammatory changes. Although this is a rare syndrome in developed countries (0.7-1.4 %), preoperative diagnosis and careful surgical management are essential to avoid bilio-vascular injuries and misdiagnosed malignancy. METHODS: The purpose of this study was to review our experience in the diagnosis and management of MS, assess the role of laparoscopy and the risk of concomitant gallbladder carcinoma. This study took place in a large county hospital which serves indigent and undocumented immigrants without easy access to healthcare. Data were collected through a retrospective chart review of 4939 patients that underwent cholecystectomy over 6 years. Patient demographics, preoperative, intraoperative, postoperative data and outcomes were analyzed. RESULTS: MS was identified in 60 of 4939 patients (1.21 %) who underwent cholecystectomy. The mean age at presentation was 47 years, and 35 patients were females. The most common symptom at presentation was abdominal pain (100 %) followed by nausea/vomiting (87 %) and jaundice (43 %). Type I MS was diagnosed in 16 patients and 44 had type II MS. Preoperative diagnosis was achieved in 43 patients (71 %). Magnetic resonance cholangiopancreatography was the best diagnostic modality. Laparoscopic cholecystectomy was successful in 4 out of 16 patients with type I MS. Three patients (5.26 %) had simultaneous gallbladder cancer. Overall morbidity was 27 % and mortality was 0. Clavien grade ≥3 complications were seen in six patients (10 %). The mean length of follow-up was 2.3 months (range 0-5) for type I MS patients and 5.4 months (range 0-46) for type II patients. CONCLUSIONS: MS is rare, but preoperative diagnosis or intraoperative suspicion is important. Laparoscopic cholecystectomy may be possible in selected type I cases. Open cholecystectomy is the standard of care for type II MS.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

[Endoscopic interventions in diagnosis and treatment of Mirizzi syndrome]. / Endoskopicheskie vmeshatel'stva v diagnostike i lechenii sindroma Mirizi.

AIM: To define the role of endoscopic interventions in diagnosis and treatment of Mirizzi syndrome. MATERIAL AND METHODS: Results of treatment of 41 patients with Mirizzi syndrome are presented. Endoscopic transpapillary interventions including cholangiography, papillosphincterotomy lithoextraction, nazobiliary drainage were used as a first step in all cases. RESULTS AND DISCUSSION: In 4 cases laparoscopic cholecystectomy was performed after biliary tree sanitation. In 6 advanced age patients with severe comorbidities common bile duct stenting alone was preferred. Open interventions were performed in 15 patients (36.6%) including cholecystectomy, choledocholithotomy with common bile duct drainage. CONCLUSION: It is shown that endoscopic transpapillary methods of diagnosis and treatment of Mirizzi syndrome provides adequate decompression and sanitation of the bile ducts in most cases and significantly reduces number of open surgical procedures.

[RESULTS OF TREATMENT FOR MIRIZZI SYNDROME].

Results of diagnosis and treatment of 21 patients, suffering Mirizzi syndrome (MS), were analyzed. Informativity of ultrasound investigation and endoscopic retrograde cholangiopancreatography in diagnosis of MS types I and II was presented. The first stage of treatment consisted of endoscopic interventions ­ lithotripsy with lithoextraction, the biliary ducts stenting, nasobiliary drainage. In 14.3% of patients surgical treatment was not necessary after endoscopic interventions. Variants of surgical treatment for MS were analyzed. In MS type I in 5 patients cholecystectomy was performed, and for type II ­ partial cholecystectomy with biliary ducts plasty ­ in 11, cholecystofistulolithotomy ­ in 2, hepaticojejunostomy ­ in 1.

[Diagnosis and surgical treatment of mirizzi syndrome].

Retrospective analysis of the surgical treatment results in 34 patients, operated for intraoperatively diagnosed Mirizzi syndrome (MS), was done. Analysis of intraoperative changes have witnessed, that while transition occurrence of MS from the first to the fifth type a severity of morphological changes in a gallbladder-biliary ducts-duodenum system enhanced with duodenal integrity loss and development of cholecystobiliary or cholecystodigestive fistula. Surgical correction of MS have envisaged cholecystectomy performance or subtotal resection of gallbladder, plastic closure of biliary fistula, using various procedures, external biliary draining and formation of hepaticojejunostomy in accordance to Roux method.

Multidisciplinary management of Mirizzi syndrome with cholecystobiliary fistula: the value of minimally invasive endoscopic surgery.

Mirizzi syndrome, a rare complication of gallstones, is defined by obstruction of the main bile duct. This obstruction may worsen and thus result in cholecystobiliary fistula. Surgical management of Mirizzi syndrome is complicated by the presence of inflamed tissue around the hepatic pedicle, making it impossible to distinguish between the main bile duct and the gallbladder. The surgeon's first task is to perform subtotal cholecystotomy (from the fundus of the gallbladder to the neck) without trying to locate the cystic duct. In a second step, the gallstones are extracted and the main bile duct is then repaired. In most cases, a T-tube is used to drain the main bile duct, and abdominal drainage is left in place (in case a bile fistula forms). This study concluded that preoperative drainage of the main bile duct in the treatment of Mirizzi syndrome types II and III is feasible and might help to decrease the postoperative complication rate.

[FEATURES OF THE MIRIZZI SYNDROME TREATMENT].

Analysis of the possibilities of application of minimally invasive approaches in Mirizzi syndrome. Analyzed the treatment of 70 patients with the syndrome Mirizzi treated from 2002 to 2012. The study describes the features of the application of minimally invasive interventions in Mirizzi syndrome. Application of minimally invasive techniques in the treatment of Mirizzi syndrome is permissible when assessing the diagnostic characteristics obtained at the preoperative and intraoperative phases. Frequency conversion during minilaparotomic access at Mirizzi syndrome lower than for laparoscopic. Performing intraoperative cholangiography before main stages of the opera helps to concretize optimum volume of intervention.