Minimally invasive management of type IV Mirizzi syndrome using a laparo-endoscopic approach and ICG fluorescence (with video)

Type IV Mirizzi syndrome is a rare and particularly complex biliary condition characterized by a cholecystocholedochal fistula caused by an impacted gallstone that completely obstructs the bile duct lumen. This scenario produces severe chronic inflammation, dense adhesions at the hepatic hilum, and a very limited healthy ductal segment available for reconstruction. Open surgery has traditionally been the preferred approach. However, recent advances in minimally invasive surgery and the incorporation of fluorescence-guided technology using indocyanine green (ICG) have enabled selected cases to be managed laparoscopically with precision and safety in experienced centers. A 73-year-old woman with a history of hypertension and type 2 diabetes who presented with two weeks of jaundice and right upper quadrant pain. Computed tomography and MR cholangiography revealed an atrophic gallbladder with an impacted stone compressing the common hepatic duct, associated with upstream biliary dilation findings consistent with type IV Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and allowed placement of an 8.5 Fr plastic biliary stent, resulting in clinical improvement. Definitive surgical treatment was performed laparoscopically and consisted of subtotal cholecystectomy, resection of the extrahepatic bile duct up to the biliary confluence, and Roux-en-Y hepaticojejunostomy reconstruction. ICG fluorescence imaging was used throughout the dissection and anastomosis to enhance visualization of biliary structures under near-infrared light. The postoperative course was uneventful, with discharge on the third day. This case highlights the feasibility and safety of a minimally invasive, fluorescence-guided approach for complex Mirizzi syndrome, offering reduced morbidity and faster recovery compared with traditional open surgery.