ICG-Fluorescence guided laparoscopic treatment for type III Mirizzi Syndrome: A video vignette

Abstract text (incl. references and figure legends)

INTRODUCTION Mirizzi syndrome (MS) is a rare and challenging complication of cholelithiasis. Surgery is almost always required for definitive treatment, and the feasibility of a laparoscopic treatment is still controversial, with high conversion rates. Definitive preoperative diagnosis is essential to attempt a laparoscopic approach. ICG-Fluorescence guided laparoscopic cholecystectomy is nowadays recognized as a cost-effective method, able to improve intra-operative visualization, both in routine and complicated cases. Nevertheless, no cases of fluorescence guided surgery for MS have yet been reported.

M&M We describe the case of a 72 years old patient, with preoperative diagnosis of Mirizzi syndrome and endoscopic double biliary stent placement for complete lithiasic choledochal obstruction.

RESULTS The patient underwent laparoscopy after ICG injection and the intraoperative finding was a MS type III, with a complete fusion of Hartmann pouch (occupied by the stone) with common bile duct. The video shows how the fluorescence was essential in identifying the residual, healthy wall of CBD and the limit between this one and the Hartmann pouch, where the fistula was located, thus guiding the surgeon during infundibulotomy for stone removal. The post-operative course was uneventful.

CONCLUSIONS In the treatment of a complicated case of MS, ICG-fluorescence might be a very useful tool, allowing more widespread use of laparoscopic approach, reducing conversion rate and ensuring the best visualization of CBD anatomy.

REFERENCES

Chen H et al. Current trends in the management of Mirizzi Syndrome. Medicine 2018; 97:4(e9691)

Zhao J et al. Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review. Surgical Endoscopy 2020 34:4717–4726

Reeves JJ et al. The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy. Surgery 2022;171(5):1168-1176

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