Transinfundibular Cholangioscopy-Guided Laparoscopic Management of Fistulized Mirizzi Syndrome with Giant Stone Migration: A Case Report

Abstract

Background: Mirizzi syndrome is an uncommon complication of chronic gallstone disease caused by an impacted stone in the gallbladder infundibulum or cystic duct, leading to extrinsic compression of the common bile duct. Advanced disease may progress to cholecystobiliary fistula formation, resulting in distorted biliary anatomy and a substantial risk of bile duct injury during surgery. The role of intraoperative cholangioscopy in guiding laparoscopic management of these complex cases remains poorly documented. Case presentation: A 60-year-old woman presented with progressive jaundice and right upper quadrant pain. Initial computed tomography demonstrated biliary dilatation secondary to common bile duct stones but did not suggest Mirizzi syndrome. Magnetic resonance cholangiopancreatography confirmed biliary obstruction without clearly identifying a cholecystobiliary fistula. During laparoscopic exploration, severe inflammatory changes precluded safe dissection of Calot's triangle, prompting a bailout strategy with infundibulotomy. Transinfundibular intraoperative cholangioscopy unexpectedly revealed a cholecystobiliary fistula through which a giant stone had migrated into the common bile duct. Laparoscopic choledochotomy allowed extraction of the impacted stone, followed by cholangioscopy-guided removal of two residual distal stones. Primary closure of the common bile duct and subtotal laparoscopic cholecystectomy were successfully completed. A low-output postoperative bile leak resolved with conservative management. Conclusion: This case highlights the value of transinfundibular intraoperative cholangioscopy in the management of advanced fistulized Mirizzi syndrome. By providing direct visualization of the biliary anatomy and fistulous communication, this technique facilitated surgical decision-making, complete bile duct clearance, and successful laparoscopic treatment while minimizing the risk of major bile duct injury.