Surgical challenges in Mirizzi's syndrome from retained cystic duct - common bile duct junction stones after subtotal cholecystectomy

Abstract

Introduction: Mirizzi’s syndrome arising from retained cystic duct – common bile duct junction (CD-CBDJ) stones following initial subtotal cholecystectomy is an uncommon but challenging condition to treat. Method: We retrospectively reviewed all cases treated for Mirizzi’s syndrome from Mar 2018 till Feb 2019 and identified 3 cases of retained CD-CBDJ stones. All of these cases had a laparoscopic subtotal cholecystectomy initially due to difficult dissection at the Calot’s triangle. They presented post-operatively with obstructive jaundice and imaging revealed Mirizzi’s syndrome secondary to retained CD-CBDJ stones. Their clinicopathological characteristics were reviewed. We present a literature review regarding the subject, and highlight the surgical challenges in their management. Result: The retained CD-CBDJ stone presents a unique set of challenges for the hepatobiliary surgeon. The dissection is challenging as the plane between the cystic duct (CD) and the common bile duct (CBD) is often obliterated. A subtotal cholecystectomy is inadequate for retrieving a CD-CBDJ stone, yet a choledochectomy may not be able to adequately identify or access such a stone depending on the level of insertion of the cystic duct and the degree of fibrosis. Additionally, closure of the choledochotomy may be challenging if the CBD is of narrow calibre. Conclusion: While rare, the retained CD-CBDJ stone causing Mirizzi’s syndrome after subtotal cholecystectomy can be uniquely challenging to treat. We suggest that early recognition of this disease entity, clear anatomical studies, acknowledging its surgical challenges and embracing a multimodal approach with endoscopy and surgery may be the best way forward in addressing this complication of subtotal cholecystectomy.