382 Total Laparoscopic Management of Mirizzi Type VA Using a Transvesical Approach for Confirmation of Cholecysto-Duodenal Fistula and CBD Exploration

Abstract Introduction Mirizzi syndrome is a rare complication of gallstone disease, seen in about 0.1% of patients with cholelithiasis. It involves external compression or erosion of the common hepatic duct (CHD) by a stone impacted in the cystic duct or gallbladder neck. Incidence at cholecystectomy ranges from 0.7% to 25%. Higher-grade cases (Types II–V), especially with cholecystoenteric fistulae, are often managed with open surgery. Method A 72-year-old woman presented initially with acute cholecystitis and deranged liver function tests. MRCP revealed Mirizzi syndrome with choledocholithiasis. First ERCP: Two small CBD stones were removed; one large stone remained. A biliary stent was placed. Readmission: She developed cholangitis. Repeat MRCP showed a cholecystocholedochal fistula with an impacted CBD stone. Second ERCP: Due to large, impacted stone two pigtail catheters were placed for drainage and surgery was planned. She underwent laparoscopic subtotal cholecystectomy. A transvesical approach allowed anatomical confirmation and radiological mapping allowed safe CBD exploration after transection of cholecystoduodenal fistula. Lithotripsy required to fragment and extract the impacted stone. The gallbladder remnant closed using absorbable suture in 2 layers helped to cover the bile duct defect, avoiding bilioenteric reconstruction. Results Postoperative MRCP on day 4 and at 7 months showed complete clearance and near-normal remodelling. Recovery was uneventful. No readmissions till date. Conclusions Laparoscopic transvesical CBD exploration with lithotripsy and native tissue repair is a feasible, safe alternative to open surgery in selected cases of complex Mirizzi syndrome (Type Va).