Subtotal Cholecystectomy with Repair of a Choledochal Defect Using the Posterior Wall of the Gallbladder in Mirizzi Syndrome Type IIA: Comparison of Three Surgical Approaches

Abstract

Mirizzi syndrome type II is a rare complication of gallstone disease characterized by the formation of a cholecystocholedochal fistula with a partial defect of the common bile duct wall. Pronounced inflammatory and fibrotic changes in the hepatoduodenal ligament area complicate surgical treatment, increase the risk of intraoperative and postoperative complications, prolong hospital stay, and intensify postoperative pain syndrome. Objective. To evaluate the efficacy and safety of subtotal cholecystectomy with repair of a choledochal defect using the posterior wall of the gallbladder in Mirizzi syndrome type IIA, depending on the type of surgical approach. Materials and methods. A retrospective analysis was conducted of the treatment outcomes of 56 patients with Mirizzi syndrome type IIA according to our proposed classification, defined as the presence of a cholecystobiliary fistula with a bile duct wall defect not exceeding onethird of its circumference. The patients were treated between 1997 and 2025. Group I included 26 patients who underwent mini-laparotomic subtotal cholecystectomy with repair of the choledochal defect using the posterior wall of the gallbladder; Group II included 11 patients who underwent the laparoscopic variant of this procedure; and Group III included 19 patients treated through a laparotomic approach. The frequency of intraoperative and early postoperative complications, duration of hospital stay, intensity of postoperative pain according to the visual analogue scale, and the need for narcotic analgesics were assessed. The overall frequency of intraoperative and early postoperative complications was 11.5% in Group I, 9.1% in Group II, and 26.3% in Group III. The difference in complication rates among the three groups was descriptive and did not reach statistical significance (χ²=2.27; p=0.321). The mean duration of hospital stay was 8.1±1.6 days in Group I, 7.2±1.4 days in Group II, and 12.6±2.8 days in Group III; the differences between the mini-laparotomic and laparotomic groups, as well as between the laparoscopic and laparotomic groups, were statistically significant (p<0.001). The lowest intensity of postoperative pain was observed after laparoscopic surgery, moderate pain intensity after the mini-laparotomic approach, and the highest pain intensity after laparotomy. The need for narcotic analgesics was highest in Group III (42.1%) compared with Group I (11.5%) and Group II (9.1%). Results and discussion. The obtained results indicate that the choice of surgical approach in Mirizzi syndrome type IIA should be based on intraoperative assessment of anatomical conditions, the severity of the inflammatory infiltrate, and the feasibility of safe repair of the choledochal defect. The laparoscopic approach was associated with lower postoperative trauma, whereas mini-laparotomy may be an appropriate intermediate option in complex cases. Laparotomy should be considered a reserve approach when safe completion of the procedure by less invasive methods is not possible. Conclusions. The authors established that subtotal cholecystectomy with repair of a choledochal defect using the posterior wall of the gallbladder is a technically feasible method for the treatment of Mirizzi syndrome type IIA, while the mini-laparotomic approach may be an appropriate intermediate option between laparoscopic and laparotomic approaches in complex anatomical conditions