Acute Mirizzi Syndrome

BACKGROUND: Mirizzi syndrome is a rare complication of cholecystolithiasis characterized by jaundice due to compression of the common hepatic duct. The diagnosis may not be immediately apparent, and management is controversial with open surgery still recommended by some authors. METHOD: A case is detailed herein of a 67-year-old man who presented with abdominal pain, fever, and jaundice. A dilated bile duct was found on ultrasound, but the gallbladder could not be seen. The diagnosis of Mirizzi syndrome was made at ERCP, and a stent was placed through the papilla. Laparoscopic retrograde (fundus first) cholecystectomy was carried out utilizing a laparoscopic liver retractor. RESULTS: In this particular case, it was not possible at ERCP to get a guidewire and stent past the obstruction. A stent was left through the papilla, below the obstruction and this allowed primary duct closure during surgery. CONCLUSION: Acute Mirizzi syndrome should be suspected when a patient presents with acute cholecystitis and jaundice with dilated intrahepatic ducts on ultrasound. ERCP is useful to confirm the diagnosis and allows stenting to alleviate the jaundice and facilitate the subsequent operation. Laparoscopic ultrasound is useful to locate the impacted stone and to partially replicate the touch of the surgeon's hand, which is not available in laparoscopic surgery.