Robotic Management of Mirizzi Syndrome Type IV with Cholecystocolic Fistula: A Rare Case Report

Abstract

Introduction: Mirizzi syndrome (MS) is a rare complication of prolonged cholelithiasis, with presence of a large gallstone impacted in Hartmann’s pouch, causing chronic extrinsic compression of the common bile duct, and potentially leading to fistula formation between the gallbladder and the common bile duct and/or bowel. Laparoscopic management is widely accepted for MS type I/II, whereas open surgery is the preferred approach for MS type III/IV and presence of a cholecystoenteric fistula. Robotic surgery has the advantage of 3D visualization and endowrist technology, helping to operate more accurately compared to laparoscopy, and could provide an appropriate alternative surgical approach. This report describes the robotic management of a MS type IV with cholecystocolic fistula. Method: The surgical procedure involved a robotic cholecystectomy with a small wedge excision of segment 4B/5 junction, extrahepatic bile duct resection, evacuation of major choledocholithiasis, and wedge excision of a cholecystocolic fistula at the transverse colon. Biliary enteric anastomosis was realized by Roux-en-Y hepaticojejunostomy. The colon was closed using a Heineke-Mikulicz plasty. Dissection was done by monopolar scissors, fenestrated bipolar forceps and robotic sealing device. Results: Operative time was 240 minutes and blood loss 30 cc. Pathology showed chronic cholecystitis without underlying malignance. No intraoperative complications were encountered and the postoperative course was uneventful. Discharged happened on postoperative day 5. Conclusions: Robotic surgery is a safe and feasible technique for MS type IV with cholecystocolic fistula.