Page 20 - Journal of WALS

10.5005/jp-journals-10007-1155
George Chilaka Obonna, RK Mishra
REVIEW ARTICLE
Role of Robotic Surgery in the Treatment of

Mirizzi Syndrome

George Chilaka Obonna, RK Mishra

1
ABSTRACT longstanding cholelithiasis and cholecystitis, erroneously
postulating that the extrinsic pressure and inflammation
Mirizzi syndrome (MS) is a rare complication of cholelithiasis.
It presents as a spectrum of disease that varies from extrinsic induced spasm of the common bile duct. The classic
compression of the common hepatic duct to the presence of a description of the disease includes four components: (1) A
cholecystobiliary fistula. This dangerous alteration to anatomy close parallel course of the cystic duct and the common
if not recognized preoperatively has the potential to lead to hepatic duct, (2) an impacted stone in the cystic duct or the
significant morbidity and billiary injury particularly in the
laparoscopic era. neck of the gallbladder (GB), (3) common hepatic duct
obstruction secondary to external compression by cystic duct
Aim: To study the role of robotic surgery in the treatment of MS
having in mind the various types of the syndrome. stone (and the surrounding inflammation), (4) jaundice with
or without cholangitis.
Methods:Literature review from HighWire press, PubMed, Mirizzi syndrome (MS) is a rare complication of
Medline, goggle, SpringerLink, Wikipedia relevant documents,
templates, forms, E-books and Cochrane database was cholelithiasis with an estimated incidence of 0.05 to 2.7%
2-4
conducted. Analysis of other publications and journals from and approximately 0.35% of cholecystectomies. The main
robotic surgical institute was done, including live robotic surgery classifications of MS are by Csendes, Nagakawa and Sherry.
and robotic clinical videos. 5
In the Csendes classification:
Results: When a preoperative diagnosis is made through Type 1: Those with external compression of the common
endoscopic stent insertion via endoscopic retrograde hepatic duct by stone impacted in the cystic duct.
cholangiopancreatography (ERCP) with computed tomographic
(CT) scan or intraoperative exploration and assessment with Type 2: Cholecystocholedochal fistula is present with
ultrasonography establishes Mirizzi types 1 or 2, the current erosion of less than one-third of the circumference of the
robotic surgical system offers an effective treatment of the common hepatic duct.
syndrome. With the ultra high magnification of the surgical field Type 3: Fistula involves up to two-thirds of the duct
and the endowristed 7 degrees of refined movement together circumference.
with an enhanced clinical capability and integration of
electrosurgical device, detailed and careful cholecystectomy and Type 4: there is complete destruction of the common
even primary closure of common hepatic duct fistula can be hepatic duct.
perfected. Types 3 and 4 by Nagokawa defined type 3 as hepatic
Conclusion: Combined endoscopic and robotic surgery is duct stenosis due to a stone at the confluence of the hepatic
effective and safe in the treatment of MS types 1 and 2. Definitely cystic ducts and type 4 as hepatic duct stenosis as a
robotics has a role to play in the treatment of MS. During complication of cholecystitis in the absence of calculi
cholecystectomy, partial resection is possible in order to extract impacted in the cystic duct or GB neck. 6
the stones,visualize the bile duct and define the type and location
of the fistula. T-tube could be placed distal to the fistula in the McSherry only talked about extrinsic compression of
absence of a preoperative stent. However, complete removal the common hepatic duct (type 1) and presence of
of the gallbladder is now advocated because of the increased cholecystobiliary fistula (type 2). 7
risk of malignancy in stone disease. Precise diagnosis may be difficult initially because the
Keywords: Mirizzi syndrome, Robotic cholecystectomy, condition may be confused with choledocholithiasis and
da Vinci, Endoscopic retrograde cholangiopancreatography. cholangitis. The classical ultrasound findings are of a

How to cite this article: Obonna GC, Mishra RK. Role of contracted GB, dilated intrahepatic ducts and a normal
Robotic Surgery in the Treatment of Mirizzi Syndrome. World common bile duct.
J Lap Surg 2012;5(2):80-84. Although a rare condition, a combination of endoscopic

Source of support: Nil retrograde cholangiopancreatography (ERCP) and robotic
surgery will ensure proper treatment of the patient. The role
Conflict of interest: None declared
of the current da Vinci surgical system is hereby highlighted
from its operational intuition.
INTRODUCTION
It was in 1948, Argentinean surgeon Pablo Luis Mirizzi, METHODOLOGY
Professor of surgery in Cordoba first described a syndrome This author was present in a live da Vinci Si robotic
of common hepatic duct obstruction in the setting of cholecystectomy performed by Professor RK Mishra at the
80
JAYPEE