PMC3015902_01
ERCP showing a stone (arrow) obstructing the bile duct.
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F1
At ERCP, contrast filled a nondilated CBD up to an obstruction due to a stone (Figure 1).
ERCP confirming Mirizzi syndrome with the guidewire in the gallbladder (GB). The stone is impacted in the cystic duct, which is anterior and parallel to the common hepatic duct. Note the narrow common bile duct and the dilatation of the common hepatic and intrahepatic ducts.
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F2
The guidewire kept going into the gallbladder, and it became apparent that there was an MS with the obstructing stone in the cystic duct causing compression of the CHD (Figure 2).
Computed tomograpic scan showing a calcified stone causing bile duct obstruction with the proximal end of the stent just below the stone. Residual contrast from the ERCP is present in the gallbladder (Somatom volume zoom, 4 slice, Siemens AG, Erlangen, Germany).
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F3
A computed tomogram (CT) scan was done and showed a contracted gallbladder with a calcified stone causing biliary obstruction (Figure 3).
The gallbladder (GB) has been dissected from the liver retrograde, and the liver retractor is in place. The arrow points to Surgicel (Ethicon, Somerville, NJ, USA) in the gallbladder bed of the liver.
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F4
A liver retractor was used to elevate the liver and maintain exposure of the bile duct (Diamond-Flex, Cardinal Health, Snowden-Dencer MIS Products, Tucker, GA, USA) (Figure 4).
Laparoscopic ultrasound image showing the impacted stone (arrow) in a thickwalled duct (Aloka Inc., Japan).
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F5
It was possible to "feel" the stone via a grasper, and its position was definitely confirmed by laparoscopic ultrasound (Figure 5).
Incising the bile duct to release the stone.
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F6
Bristol, UK. www.espinermedical.com) (Figure 6).
Choledochoscopy using a 5-mm scope showing a clear bile duct with the stent visible (insert).
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F7
The CBD was examined with a 5-mm flexible choledochoscope showing that the duct was clear distally with the stent in place (Figure 7).