BackgroundMirizzi syndrome (MS) is a complicated form of longstanding, symptomatic cholelithiasis. According to Beltran Classification MS Type V has been introduced to describe the cholecystoenteric fistula, with or without gallstone ileus. Mirizzi syndrome Type V with double fistula has been reported in the past; however, the triple fistula is an even rarer case, first described in the international literature so far.Case presentationA 77-year-old male was admitted to our surgical department with recurrent episodes of abdominal pain, which initially presented in the last 6 months and was accompanied with jaundice. Computed tomography showed findings of cholelithiasis, pneumobilia and choledocholithiasis. We performed an ERCP, which showed two fistulas of the gallbladder with the pyloric antrum and the duodenum, respectively. Surgical treatment was immediately undergone and during laparotomy, we confirmed these findings. We ligated and dissected these communications. In addition, a third fistula between the gallbladder and the common bile duct was identified. An insertion of a Kehr T-tube into the common bile duct was performed via the gallbladder. After 3 months, the Kehr T-tube was removed and in the subsequent 2 years of follow-up the patient was presented without complications.ConclusionsMirizzi syndrome complicated with triple fistula, first described in the international literature, to the best of our knowledge, confirms the long natural history of inflammation.