REVIEW

Laparoscopic treatment of Mirizzi syndrome: a systematic review

Stavros A. Antoniou Æ George A. Antoniou ÆCharalambos Makridis

Received: 16 January 2009 / Accepted: 22 April 2009 / Published online: 23 May 2009

� Springer Science+Business Media, LLC 2009

Abstract

Background This article reviews the feasibility of the

laparoscopic treatment of Mirizzi syndrome and determines

the associated risks and complications of this technique.

Methods An electronic search of the literature between

1989 and 2008 was undertaken to identify relevant articles.

Studies comprising at least four patients treated by lapa-

roscopy and reporting on the preoperative diagnosis rate

and analytical conversion and complication data were

considered for inclusion.

Results From 66 abstracts reviewed, 10 eligible studies

were identified. Conversion, complication, and reoperation

rates were 41%, 20%, and 6%, respectively. The risks for

open conversion and procedure-related complications were

similar for patients with type I and type II Mirizzi syn-

drome. However, patients of studies reporting a high pre-

operative diagnosis rate had a significantly lower risk for

conversion (p \ 0.05), procedure-related complications

(p \ 0.05), and reoperation (p \ 0.05), when compared

with studies with a low preoperative diagnosis rate.

Conclusion Current evidence suggests that laparoscopic

treatment of Mirizzi syndrome cannot be recommended as

a standard procedure. Preoperative diagnosis of the syn-

drome seems an important predicting factor of technical

success.

Keywords Mirizzi syndrome � Cholecystobiliary fistula �Laparoscopy � Laparoscopic cholecystectomy � Review

Mirizzi syndrome (MS) is an uncommon complication of

gallstone disease, with a reported incidence between 0.06%

and 5.7% in patients undergoing cholecystectomy [1, 2].

The condition was originally described by Kehr in 1905

[3], but it was named after Pablo Mirizzi several years

later, who defined the syndrome as a benign common

hepatic duct obstruction due to gallstone impaction in the

gallbladder neck resulting in local inflammation and bile

duct spasm [4]. As it was eventually recognized that there

is no physiological sphincter of the hepatic duct, MS was

finally attributed to extrinsic compression of the common

hepatic duct by gallstones impacted in the cystic duct or the

gallbladder neck [5]. Bile duct wall necrosis and sub-

sequent cholecystobiliary fistula caused by chronic

inflammation is a rare sequence of the disease.

The most widely accepted classification of MS was

proposed by McSherry et al. [6], who described two types:

type I includes partial or complete obstruction of the

common hepatic duct due to external compression; type II

refers to the formation of a communication between the

gallbladder neck or the cystic duct and the common hepatic

duct. Csendes et al. further subclassified cholecystobiliary

communication into three types according to the diameter

of the biliary fistula [7]. In this classification, type II is a

cholecystobiliary fistula that involves less than one-third of

the circumference of the bile duct, type III is a fistula that

involves up to two-thirds of the bile duct circumference,

and type IV is a fistula with complete bile duct destruction.

The classification suggested by McSherry et al. was used in

this systematic review.

This review will be presented in the 9th Panhellenic Congress of

Laparoendoscopic Surgery and International Symposium

‘‘Collaboration for Surgery Evolution’’ May 21–23, 2009, Athens,

Greece.

S. A. Antoniou (&) � G. A. Antoniou � C. Makridis

First Surgical Department, Papageorgiou General Hospital,

Thessaloniki Ring Road, 564 29 Thessaloniki, Greece

e-mail: stavros.antoniou@hotmail.com

123

Surg Endosc (2010) 24:33–39

DOI 10.1007/s00464-009-0520-5

The treatment of MS is mainly surgical and consists of

partial or complete cholecystectomy with or without com-

mon bile duct exploration. Choledochoplasty with a gall-

bladder flap and T-tube placement may be required in

complex cases, but extensive erosions of the bile duct are

best managed with a bilioenteric anastomosis [5, 8]. Endo-

scopic retrograde cholangiopancreaticography (ERCP) may

be the only option for poor surgical candidates. Electrohy-

draulic and extracorporeal shock wave lithotripsy have also

been described as alternatives to surgical therapy [9, 10].

Shortly after the advent of laparoscopy in the treatment

of gallbladder diseases, Rust et al. suggested that MS may

be a contraindication for laparoscopic cholecystectomy

[11]. In 1992, Paul et al. reported the first successful lap-

aroscopic treatment of type I MS [12]. Several cases were

described thereafter; this new method, however, has not

gained wide acceptance, partly because of the lack of large

series due to the rarity of the syndrome and the contro-

versial results of different reports.

The purpose of the present study was to systematically

review the literature in order to analyze the preoperative

investigation methods, the outcome, and the complications

of the laparoscopic treatment of MS.

Methods

Search strategy

A public-domain database (MEDLINE) was searched using

a web-based search engine (PubMed) for articles published

between December 1989, when the technique of laparo-

scopic cholecystectomy was first described, and December

2008. The literature search was confined to studies pub-

lished in English and German. The keywords used were

‘‘Mirizzi syndrome AND laparoscopy’’ and ‘‘Mirizzi syn-

drome AND laparoscopic cholecystectomy.’’ Abstracts of

the articles found were scrutinized to identify the original

articles. The full text of each original article was then

obtained. Manual cross-referencing was also carried out,

based on the bibliography of articles identified in the pri-

mary search, to ensure inclusion of all possible studies. The

literature search, study selection, and data extraction from

the relevant studies were performed by two independent

authors (S.A.A., G.A.A.).

Study selection

Studies were considered for inclusion based on the fol-

lowing criteria: (1) they included at least four patients with

MS who were treated by laparoscopy, (2) they reported on

the preoperative diagnosis rate, and (3) they reported on

analytical conversion and complication data.

Data abstraction and statistical analysis

Data abstracted, where available, from individual studies

were: type of study (prospective or retrospective), number

of patients with MS, number of patients with MS treated by

laparoscopy, duration of follow-up, demographic charac-

teristics of the study population, MS type I/MS type II

ratio, preoperative diagnosis rate, sensitivity of each diag-

nostic tool, conversion rate, conversion rate according to

type of MS, reason for conversion, complication rate,

complication rate according to type of MS, reoperation

rate, reoperation rate according to type of MS, and days of

in-hospital stay.

The statistical analysis was performed using the two-

tailed Fisher’s exact probability test, in order to compare

the outcome between study groups with a high or low

preoperative diagnosis rate of MS. The same statistical test

was used to compare the outcome between MS type I and

MS type II patients. A p value less than 0.05 was consid-

ered statistically significant.

Results

Search results

Sixty-six abstracts were initially located, and 15 relevant

articles were retrieved. Ten of these articles fulfilled the

inclusion criteria [13–22]. The reasons for rejection were:

non-English and non-German articles (20), fewer than four

patients treated laparoscopically (20), open or other types

of treatment (4), inadequate complication data (3), reviews

(1), letters to the editor (1), and not related articles (7)

(Fig. 1). The ten recruited studies with details on their

characteristics are summarized in Table 1.

Fig. 1 Flow chart of search history

34 Surg Endosc (2010) 24:33–39

123

Characteristics of the study population

The ten manuscripts identified 135 patients with MS; lap-

aroscopic treatment was attempted in 124 of these patients.

In one study, a patient with unspecified type of MS was

excluded from the laparoscopic approach [13]. In another

study, all patients with type II MS were subjected to open

cholecystectomy and were excluded from further analysis

[22]. MS type I/MS type II ratio varied substantially among

different reports (Table 2). The male/female ratio was

1:3.2 in the eight publications providing data on patient

sex. The median age in the nine studies providing data on

age was 61 years (range 44–68 years). It is clear from

Table 3 that there is significant heterogeneity in the pre-

operative diagnosis rate of MS among the different studies.

Most studies reported the use of ERCP and/or ultraso-

nography in order to confirm the diagnosis of MS; ERCP

was proved to be the most reliable assessment tool and

identified MS in 76.2%.

Technical success

Of a total of 124 patients, laparoscopic treatment of MS

was successful in 73 patients (59%); conversion was

required for 51 (41%) (Table 4). Seven studies provided

information on conversions for each MS subtype. Con-

version to open surgery was required in 32 of 68 patients

with type I MS (47%) and in 7 of 16 patients with type II

MS. Table 5 summarizes the reasons for open conversion

sorted by frequency. The most common reason for con-

version was adhesions around the Calot’s triangle, fol-

lowed by uncertain or abnormal biliary anatomy.

Complications and reoperations

Table 6 shows the complication and reoperation rate for

each individual study. The mean complication rate was 20

of 124 (16%). Additionally, Table 6 shows the procedure-

related complications sorted by frequency. Bile duct injury

and residual lithiasis were the most common complica-

tions, occurring in five patients each. Minor bile leakage

complicated three cases. Isolated incidents of pancreatitis,

biliary peritonitis, duodenal laceration, and intra-abdomi-

nal abscess were also reported. One procedure-related

death was reported in the literature [14], due to biliary

peritonitis and septic shock, accounting for a mortality rate

of 0.8%.

Reoperation was required in 6 of 124 patients: in 2

patients for a major bile duct injury, in another 2 patients

for the management of biliary peritonitis, in 1 patient to

extract a residual bile duct stone, and in another patient to

excise a gallbladder carcinoma, resulting in a reoperation

rate of 5% (Table 6). Most studies did not report on the

reoperation rate for each type of MS; therefore, the risk for

secondary intervention of each MS subgroup could not be

Table 1 Study characteristics

Authors Year Study type No. of patients

with MS

No. of patients treated

by laparoscopy

Duration of

follow-up (months)

Targarona et al. [13] 1997 Retro 5 4 3–36/mean 19

Sare et al. [14] 1998 Retro 4 4 NR

Kok et al. [15] 1998 Retro 6 6 8–17/mean 12

Vezakis et al. [16] 2000 NR 5 5 26–61/mean 37

Chowbey et al. [17] 2000 Retro 27 27 Mean 26

Bagia et al. [18] 2001 Prosp 9 9 NR

Schafer et al. [19] 2003 Prosp 39 39 NR

Yeh et al. [20] 2003 Retro 11 11 NR

Rohatgi and Singh [21] 2006 Retro 5 5 NR

Kwon & Inui [22] 2007 NR 24 14 NR

Total 135 124

NR not reported

Table 2 Patient characteristics

Authors Male

(%)

Age (mean),

years

MS type I

(n)

MS type II

(n)

Targarona et al. 40 54 NR NR

Sare et al. 25 59 3 1

Kok et al. 50 64 3 3

Vezakis et al. NR 68 2 3

Chowbey et al. NR NR 12 15

Bagia et al. 22 44 8 1

Schafer et al. 36 61 34 5

Yeh et al. 36 51 10 1

Rohatgi and Singh 20 66 2 3

Kwon and Inui 63 63 14 0

NR not reported

Surg Endosc (2010) 24:33–39 35

123

evaluated. Details on the length of hospital stay were

available in eight studies (Table 7); the median hospital

stay was 8 days (range 3–13 days).

As shown in Table 8, patients of studies reporting a high

preoperative diagnosis rate ([80%) had a significantly

lower risk for conversion (p \ 0.05), when compared with

studies with a low preoperative diagnosis rate (\80%).

Additionally, they had a lower risk for suffering procedure-

related complications (p \ 0.05), or undergoing reopera-

tion (p \ 0.05). Furthermore, MS type II patients did not

have a higher risk for conversion or procedure-related

complications, compared with the MS type I subgroup.

Discussion

The difficult surgical management of MS is due to the

presence of an intense fibrotic process and/or communi-

cation between the gallbladder and the common hepatic

duct. Since laparoscopic cholecystectomy became a routine

procedure in the early 1990s, only a few studies have been

published describing their experience with the laparoscopic

technique for the treatment of MS. They were all case

reports or case series; a randomized controlled study

comparing the open with the laparoscopic approach is

currently lacking in the surgical literature. The objectives

of this review were, therefore, to examine the feasibility of

the laparoscopic treatment of MS and to determine the

associated risks and complications.

The mean preoperative diagnosis rate was 66.1%. Most

authors reported ERCP as the preferred diagnostic proce-

dure when MS is suspected; this assessment tool had a

satisfactory mean sensitivity rate of 76.2%. Interestingly,

Kwon and Inui reported a 100% sensitivity rate for spiral

computed tomography after infusion cholangiography,

which was used in 11 of their patients [22]. This exami-

nation, however, is not widely utilized, because the contrast

agents often cause significant nausea on administration

[23]; additionally, the technique is only effective in

patients with serum bilirubin greater than 2 mg/dl [24].

Table 3 Preoperative diagnosis rates

Authors Preoperative

diagnosis

rate (%)

ERCP sensitivity

rate

U/S sensitivity

rate

PTC sensitivity

rate

CT sensitivity

rate

MRCP sensitivity

rate

SCT sensitivity

rate

Targarona et al. 3/4 (75) 3/4 0/5 – 0/1 – –

Sare et al. 3/4 (75) 2/4 0/3 1/1 – – –

Kok et al. 6/6 (100) 6/6 NR – – – –

Vezakis et al. 0/5 (0) 0/3 0/5 – – – –

Chowbey et al. 22/27 (82) 22/27 NR – – – –

Bagia et al. 3/9 (33) 0/3 2/9 – – – –

Schafer et al. 18/39 (46) NR NR – – – –

Yeh et al. 11/11 (100) 11/11 5/11 – 3/3 2/2 –

Rohatgi and Singh 2/5 (40) 1/2 1/5 – – 0/2 –

Kwon and Inui 14/14 (100) 3/3 NR – – – 11/11

ERCP endoscopic retrograde cholangiopancreaticography, U/S ultrasound, PTC percutaneous transhepatic cholangiography, CT computed

tomography, MRCP magnetic resonance cholangiopancreaticography, SCT spiral computed tomography after infusion cholangiography

Table 4 Conversion rates

Authors Conversion

rate

Conversion rate

in MS type I

Conversion rate

in MS type II

Targarona et al. 4/4 NR NR

Sare et al. 1/4 0/3 1/1

Kok et al. 1/6 1/3 0/3

Vezakis et al. 0/5 0/2 0/3

Chowbey et al. 6/27 NR NR

Bagia et al. 2/9 NR NR

Schafer et al. 29/39 24/34 5/5

Yeh et al. 4/11 3/10 1/1

Rohatgi and Singh 0/5 0/2 0/3

Kwon and Inui 4/14 4/14 NA

Total 51/124 32/68 7/16

NR not reported, NA not applicable

Table 5 Reasons for conversion

Reason for conversion Ratio (%) Conversion rate (%)

Adhesions 40.9 10.6

Uncertain/abnormal anatomy 31.8 8.2

Unsuccessful stone retrieval 13.6 3.5

Gallbladder carcinoma 4.5 1.2

Bleeding 4.5 1.2

Unsuccessful T-tube insertion 4.5 1.2

Total 100 –

36 Surg Endosc (2010) 24:33–39

123

The overall conversion rate was 41%; most common

reasons for technical failure were adhesions around

the Calot’s triangle and uncertain or abnormal anatomy of

the extrahepatic biliary system. The mean cumulative

conversion rate of studies with a preoperative diagnosis

rate greater than 80% [15, 17, 20, 22] was significantly

lower than the mean cumulative conversion rate of studies

with a preoperative diagnosis rate lower than 80% [13, 14,

16, 18, 19, 21]. Even though some authors have questioned

the value of preoperative diagnosis of MS [16, 25], it seems

to be an important predicting factor of technical success.

Wei et al. proposed the hand-assisted laparoscopic treat-

ment of MS as a simple and effective alternative to open

conversion [26]. Although their study group consisted of

unselected patients with MS type I, the proposed technique

of hand-assisted laparoscopic surgery seems an attractive

alternative for technically difficult cases; further studies

investigating the effectiveness of this method in selected

cases are, however, required.

Our analysis showed that the procedure was associated

with an overall complication rate of 16%; residual stones

and bile duct injury were the most common complications.

Csendes et al., who reported the second-largest available

case series of the open treatment of MS in the literature,

reported a procedural morbidity of 13.2%, excluding,

however, residual bile duct lithiasis [7]. After excluding

this complication in the present analysis, the laparoscopic

treatment of MS was found to be associated with a

Table 6 Complication and reoperation rates

Authors Complication rate Complication rate

in MS type I

Complication rate

in MS type II

Reoperation rate

Targarona et al. 0/4 0 0 0/4

Sare et al. 1/4 3/3 0/1 1/4

Kok et al. 0/6 0/3 0/3 0/6

Vezakis et al. 3/5 0/2 2/3 1/5

Chowbey et al. 0/27 0/12 0/15 0/27

Bagia et al. 3/9 NR NR 2/9

Schafer et al. 7/39 5/34 2/5 1/39

Yeh et al. 2/11 1/10 1/1 0/11

Rohatgi and Singh 2/5 1/2 1/3 1/5

Kwon and Inui 2/14 3/14 MA 0/14

Total 20/124 13/80 6/31 6/124

Complications Ratio (%) Complication rate (%)

Bile duct injury 25 4.0

Residual stone(s) 25 4.0

Bile leakage 15 2.4

Pancreatitis 5 0.8

Biliary peritonitis 5 0.8

Duodenal laceration 5 0.8

Intra-abdominal abscess 5 0.8

Not specified 15 2.4

Total 100 16

NR not reported, NA not applicable

Table 7 Hospital stay

Authors Days of hospital stay,

mean (range)

Targarona et al. 12 (6–21)

Sare et al. 3 (3–15)

Kok et al. 8 (5–14)

Vezakis et al. 3 (1–7)

Chowbey et al. 3 (1–5)

Bagia et al. NR

Schafer et al. 12(4–23)a, 18(11–28)b [13]c

Yeh et al. 10 (4–33)

Rohatgi and Singh NR

Kwon and Inui 8 (5–17)

NR not reporteda MS type Ib MS type IIc Mean weighted hospital stay

Surg Endosc (2010) 24:33–39 37

123

complication rate of 12%. Bile leakage complicated only 3

of 124 cases treated by laparoscopy; however, biliary

peritonitis led to septic shock and death in one case,

resulting in an overall mortality rate of 0.8% [14]. The in-

hospital mortality of the open procedure was reported to be

6.8% [7]. However, the above comparative results should

be approached with caution, because the aforementioned

study examined a population with a lower MS type I/MS

type II ratio.

Reoperation was required in six patients (5%); further-

more, higher preoperative suspicion index of MS was also

associated with a lower risk for reoperation (p \ 0.05). The

literature search for the open procedure did not provide

adequate data to allow comparative evaluation of risk for

reoperation. The mean weighted in-hospital stay was

8.4 days. This result could also not be comparatively

evaluated, as we did not identify any large series of the

open procedure reporting data on hospital stay.

The physiopathology of MS has been adequately

described during the past two decades [6, 7]. Cholecy-

stobiliary fistula is now considered an evolving stage of

longstanding gallstone disease [27]. Additionally, Beltran

et al. recently recognized cholecystoenteric fistula as a

further complication of chronic cholecystolithiasis [2]. The

reverse of the MS type I/MS type II ratio (2.1:1) observed

in the present review in contrast to several studies pub-

lished before the advent of laparoscopy [2, 7, 28] can be

attributed to the early diagnosis and treatment of patients

with gallstone disease in the laparoscopic era, and thus the

fall of the incidence of severe complications of the disease.

Csendes et al. reported a significantly higher morbidity for

patients with MS type III and IV (Csendes classification)

treated with the open procedure, when compared with the

other groups [7]. This may be explained by the physiopa-

thology of the syndrome, as cholecystobiliary fistula rep-

resents a complex sequence of MS type I, impairing the

physiological anatomic structures and making bile duct

dissection hazardous. Nevertheless, in the present review of

laparoscopic treatment of MS, there was no statistical

significance in the conversion and complication rates

between the MS subtypes, as would be expected.

From the literature reviewed, it appears that the outcome

of laparoscopic treatment of MS is not inferior to that of

open surgery, but it carries a significant conversion rate.

However, preoperative diagnosis of the syndrome is asso-

ciated with a decrease of the conversion and complication

rates to 45% and 54%, respectively. This evidence suggests

that patients with clinical suspicion of MS should undergo

an intensive diagnostic algorithm. Desai and Smink have

recommended preoperative ERCP in all patients with

jaundice and elevated liver function tests, and intraopera-

tive cholangiography in case of a negative result [29]. In

the era of minimally invasive treatment, we would suggest

solely the use of intraoperative cholangiography; if cathe-

terization of the cystic duct is unfeasible or the common

bile duct cannot be visualized, we would consider MS as a

potential diagnosis and perform intraoperative ERCP, if

available. A study comparing the aforementioned tools for

the diagnosis of MS would be of great interest.

The moderate technical success rate of the laparoscopic

treatment of MS suggests that it cannot be recommended as

a standard procedure. A stronger emphasis should be given

to the preoperative diagnosis of the syndrome, as it seems

to be associated with significantly lower risks for conver-

sion, procedure-related complications, and reoperation.

However, at least one randomized controlled trial com-

paring conventional open and laparoscopic treatment of

MS is required to consolidate these conclusions.

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