PMC4800084_01
Postoperative abdominal ultrasound showing no evidence of collection and distal common bile duct diameter of 4.6 mm.
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Abdominal ultrasound did not reveal any gallbladder fossa collection (Figure 1).
Postoperative CT scan abdomen with oral and IV contrast (axial and coronal views) showing dilated common hepatic duct (12.5 mm diameter).
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Computerized tomography of the abdomen and pelvis revealed central intrahepatic biliary duct dilation and the common hepatic duct was dilated measuring up to 1.2 cm (Figure 2).
(a) ERCP showing compression of common hepatic duct from remnant cystic duct stone (black arrow) and bile leak in background (blue arrow). (b) Fluoroscopic image after stent placement (black arrow).
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The ERCP revealed a single large 2 cm stone in the cystic duct remnant causing stenosis of the common bile duct consistent with Mirizzi syndrome along with extravasation of contrast from cystic duct stump (Figure 3).
Laparoscopic ultrasonography probe utilized to determine location of remnant cystic duct stone and common bile duct stent (blue arrow).
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During the 2nd operation, we utilized intraoperative laparoscopic ultrasonography to clearly define the presence of cystic duct remnant stone and the common bile duct stent to guide the laparoscopic dissection (Figure 4).
(a) Laparoscopic retrieval of remnant cystic duct stone. (b) Plastic common bile duct stent (pointed out by grasper) visible through the junction of cystic duct and common bile duct. (c) Laparoscopic intracorporeal closure of remnant cystic duct stump with absorbable suture.
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An incision was made directly over the cystic duct remnant and the cystic duct stone was removed (Figure 5).
Post-op ERCP demonstrating resolution of Mirizzi syndrome and no cystic duct stump leak. Balloon sweep (black arrow) of common bile duct was performed after stent removal and it revealed no common bile duct stones.
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Post-stent-removal cholangiogram revealed normal biliary tract appearance with resolution of previously noted Mirizzi syndrome (Figure 6).