"Mickey Mouse sign" to identify and remove cystic duct stones in post-cholecystectomy syndrome

Abstract

Presenter: Ajay Maker MD | University of California San Francisco Background: More than 600,000 cholecystectomies are performed in the US each year. 5-40% of these patients may go on to develop post-cholecystectomy syndrome. Biliary etiologies include common duct stricture and retained stones in the common bile duct, gallbladder remnant, or cystic duct stump. Removing retained stones in a cystic duct stump can be a challenging issue due to post-surgical scarring. Methods: We present an approach to safely and efficiently identify anatomy in the porta hepatis for surgical removal of retained cystic duct stones during cystic duct exploration. Using intraoperative ultrasound, the cystic duct, common bile duct, and portal vein can be clearly visualized. These three structures are oriented in such a way as to present a “Mickey Mouse sign” (figure). This memorable ultrasound image can be used to identify landmarks during cystic duct exploration. Results: This video demonstrates use of intraoperative ultrasound, choledochotomy, stone extraction, and primary closure as one approach for treating post-cholecystectomy syndrome. Conclusion: The novel “Mickey Mouse sign” is a helpful image that can be used to expeditiously identify anatomy and safely approach the cystic duct in post-surgical patients.