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 . 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 . 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 . 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 . mirizzi syndrome ( ms ) is biliary obstruction from compression of the common hepatic duct ( chd ) by a gallstone impacted in the cystic duct . mcsherry classified the syndrome into 2 groups : type i where extrinsic compression of the bile duct occurs and type ii where erosion occurs of the wall of the chd by the stone with formation of a cholecysto - choledochal fistula . csendes further subdivided type ii depending on the size of the fistula and the degree of destruction of the wall of the chd . the syndrome was initially described in 1948 by pablo luis mirizzi , professor of surgery in cordoba , argentina , and he erroneously postulated that the extrinsic pressure and inflammation induced spasm of the chd . precise diagnosis may be difficult initially because the condition may be confused with choledocholithiasis and cholangitis . the classical ultrasound findings are of a contracted gallbladder , dilated intrahepatic ducts , and a normal common bile duct ( cbd ) . although a rare condition , many controversial aspects still surround the definition and management of ms . to illustrate the true ms and the value of a combination of endoscopic retrograde cholangiopancreatography ( ercp ) and laparoscopic surgery , a case a 67-year - old man was admitted to the emergency department with a 3-day history of gradually worsening upper abdominal pain associated initially with vomiting and anorexia . the patient had a history of hypertension and polymyalgia rheumatica . he was noted to be jaundiced with a temperature of 38 celsius and right upper quadrant tenderness and guarding . his liver function tests were markedly deranged with bilirubin 106 mol / l [ range , 3 to 22 ] , alkaline phosphatase 159 iu / l ( range , 20 to 110 ) , and alanine transaminase 770 iu / l ( range , 5 to 65 ) . this showed dilated intrahepatic ducts with the cbd reported as also being dilated and measuring 9 mm in diameter . subsequent imaging showed that the ultrasound had actually detected a dilated chd as the cbd was not dilated . at ercp , contrast filled a nondilated cbd up to an obstruction due to a stone ( figure 1 ) . attempts were made to pass a guidewire beyond the obstruction up into the chd and intrahepatic ducts but without success . the guidewire kept going into the gallbladder , and it became apparent that there was an ms with the obstructing stone in the cystic duct causing compression of the chd ( figure 2 ) . after the guidewire had been manipulated for a time , some pus came out of the papilla signifying a gallbladder empyema . a 10 french straight plastic stent was placed through the papilla without papillotomy with its proximal tip lying below the obstruction and , as expected , no bile or intrahepatic contrast drained . the stone is impacted in the cystic duct , which is anterior and parallel to the common hepatic duct . note the narrow common bile duct and the dilatation of the common hepatic and intrahepatic ducts . a computed tomogram ( ct ) scan was done and showed a contracted gallbladder with a calcified stone causing biliary obstruction ( figure 3 ) . at laparoscopic cholecystectomy , an acutely inflamed a liver retractor was used to elevate the liver and maintain exposure of the bile duct ( diamond - flex , cardinal health , snowden - dencer mis products , tucker , ga , usa ) ( figure 4 ) . it was possible to  feel  the stone via a grasper , and its position was definitely confirmed by laparoscopic ultrasound ( figure 5 ) . the duct was incised to release the impacted stone with a single - use cbd blade ( espiner medical ltd . the cbd was examined with a 5-mm flexible choledochoscope showing that the duct was clear distally with the stent in place ( figure 7 ) . it was not possible to retroflex the choledochoscope to examine the common hepatic or intrahepatic ducts . the gallbladder was excised , the opening in the cystic duct sutured with continuous 40 vicryl ( ethicon inc . , somerville , nj , usa ) and a 20 french nonsuction tube drain placed in the subhepatic space near the bile duct . the stent was removed at ercp 6 weeks later and a check cholangiogram showed a normal bile duct with no filling of any residual cystic duct and no stricture . during 18 months of follow - up , no delayed sequelae have occurred . computed tomograpic scan showing a calcified stone causing bile duct obstruction with the proximal end of the stent just below the stone . residual contrast from the ercp is present in the gallbladder ( somatom volume zoom , 4 slice , siemens ag , erlangen , germany ) . the gallbladder ( gb ) has been dissected from the liver retrograde , and the liver retractor is in place . the arrow points to surgicel ( ethicon , somerville , nj , usa ) in the gallbladder bed of the liver . laparoscopic ultrasound image showing the impacted stone ( arrow ) in a thickwalled duct ( aloka inc . choledochoscopy using a 5-mm scope showing a clear bile duct with the stent visible ( insert ) . ms is a rare cause of jaundice due to extrinsic compression of the chd and is present in approximately 0.35% of cholecystectomies . many series report much higher rates ; however , this may represent differing views on what constitutes a case of ms . kwon and inui recently reported a prevalence of 1.2% , but only a third of their patients were jaundiced , and despite this the majority still underwent open surgery . similarly , planned open operation for mirizzi syndrome is accepted and , in fact , is still advocated by many . many surgeons do not view conversion as detrimental and therefore do not persist laparoscopically when cholecystectomy is difficult . conversion or an open operation allows the use of proprioception or the touch of the surgeon 's hand and is generally accepted as a way to improve the safety of any operation , especially one in which severe inflammation is present . to replicate this , however , open surgery is associated with significant short- and long - term morbidity , and a difficult operation is not necessarily easier or safer when performed open . a degree of tactility is possible via instruments although not by currently available robotic systems , and laparoscopic ultrasound is very useful in stone disease . it is generally accepted that an increased risk of bile duct injury exists during surgery for ms , and laparoscopic surgery may increase this risk . operative cholangiography is advocated to improve the safety of cholecystectomy , but an accurate transcystic cholangiogram will not be possible in ms . a standard technique in open surgery for the difficult laparoscopic cholecystectomy was the  fundus - first  approach . this can be replicated in laparoscopic surgery by the use of a liver retractor and means that exposure does not rely on traction on the fundus of the gallbladder . in ms , the gallbladder is often fibrosed and contracted so that fundic traction gives relatively poor exposure of the hepatobiliary triangle . also once the gallbladder is freed from the liver , the obliterated calot 's triangle can be more easily evaluated . the magnified view combined with modern instrumentation ercp may provide definitive treatment for ms ; however , the impacted stone can create real difficulties . more often , ercp is used to make the diagnosis and insert a stent to alleviate the jaundice and allow planning of an elective operation . if ercp is to be used as definitive treatment , sophisticated techniques may be needed for these cases , including the use of a  mother and baby scope  and electrohydraulic or laser lithotripsy . in the case described herein , i could have tried to break up the stone with an over the wire mechanical lithotripter , although engaging the stone in the basket may have been difficult . alternatively , a mother and baby scope and contact lithotripsy ( laser or electrohydraulic ) could have been tried but would not have been possible in my opinion because the actual cbd was not dilated and may not have taken the 5-mm baby scope . because i was planning to remove the gallbladder anyway , i preferred to leave the choledochal sphincter intact to avoid longer term risk of choledocholithiasis from a colonized biliary tract and papillary stenosis . in this case , i could not stent the obstruction from below but a percutaneous transhepatic approach could have been used . this would have been relatively straightforward as the hepatic ducts were dilated and might have been a useful strategy if this patient had been unfit for surgery . there is purportedly a 5 times higher rate of gallbladder malignancy in mirizzi sydrome compared with that in uncomplicated gallstone disease . prasad et al found 5.3% of patients with ms had gallbladder cancer compared with 1% in non - ms cases , and most were diagnosed on histology after cholecystectomy . if the patient is fit for surgery , the optimal management of ms should include cholecystectomy . the technique described leaves the choledochal sphincter intact and does not require intraoperative antegrade stenting or use of t - tubes . in ms as described herein , it would not have been easy to insert these tubes properly as the opening is into the cystic duct rather than the bile duct proper . the preoperative endoscopically placed transpapillary stent temporarily overcame the outflow resistance of the sphincter and allowed safe primary duct closure although periductal drainage was needed . in ms , even if an operation is planned , preoperative ercp and stenting should be considered because this approach should simplify and improve the safety of the operation . in addition , the fitness of the patient for surgery and the complexity of the pathology are important for planning the therapeutic approach . in my opinion , ms should ideally be treated by a combination of ercp and stenting with laparosocopic stenting overcomes the resistance of the choledochal sphincter , and even if accurate closure of the opening in a friable and inflamed duct is not possible , it should avoid the development of a significant biliary fistula . careful planning combined with modern equipment should allow most cases to be managed without t - tubes , destruction of the choledochal sphincter , or open surgery .
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 .