Page 5 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Rouviere’s Sulcus: Anatomy and its Clinical Significance

in Laparoscopic Cholecystectomy

4
1
3
2
Mohan Rao Voruganti , Nooruddin Mohammed , Ratna Chaitanya Gurrala , Gadipudi Hamika Chowdary ,
Lakshminarayana Devarakonda 5
Received on: 05 April 2023; Accepted on: 10 May 2023; Published on: 05 September 2023
AbstrAct
Background: Laparoscopic cholecystectomy (LC) is associated with an increased rate of bile duct injuries than open cholecystectomy (OC).
Majority of the bile duct injuries result from structural misidentification. The surgeon needs some anatomical landmarks to guide him for a safe
cholecystectomy. Rouviere sulcus (RVS) is one such landmark. M Henri Rouviere first described it in 1924, but it was forgotten and neglected.
It is not mentioned in anatomy or surgery textbooks. Its importance was recognized only in the late 1990s with the acceptance of LC as gold
standard surgery. As there is paucity of the literature on RVS, a study was conducted on RVS.
Materials and methods: A prospective study of RVS was conducted in 130 cases of LC noting the presence, morphology, and use of the RVS
in safe LC.
Results: Rouviere sulcus was present in 81.5% of cases. Open type sulcus with a horizontal direction was the most common presenting type.
Rouviere sulcus is an extrabiliary landmark in a solid organ, liver, which is not affected by the gallbladder disease or retraction. It is well visualized
in laparoscopic surgery than the open cholecystectomy due to opening of the sulcus by CO pressure and magnification of digital cameras. The
2
cystic duct and artery lie in a safe zone ventral and anterior to the plane of RVS and the common bile duct (CBD) lies below it. Rouviere sulcus
indicates a safe plane of dissection for surgeon to avoid bile duct injuries.
Conclusion: Rouviere sulcus is an important and first landmark that a surgeon must look to achieve the safe cholecystectomy and minimize
bile duct injuries.
Keywords: Bile duct injury, Common bile duct, Critical view of safety, Gallbladder, Laparoscopic cholecystectomy, Open cholecystectomy,
Rouviere sulcus.
World Journal of Laparoscopic Surgery (2023): 10.5005/jp-journals-10033-1553

IntroductIon 1,2,4,5 Department of General Surgery, Dr. Pinnamaneni Siddhartha
M Henri Rouviere, a French surgeon, first described Rouviere Institute of Medical Sciences and Research Foundation, Chinnaoutpalli,
sulcus (RVS) in 1924. He noticed a 2–5 cm long fissure running Andhra Pradesh, India
1
transversely between caudate process and right lobe of the liver. 3 Department of General Surgery, Asram Medical College, Eluru,
He described it as “Silon du processus caude.” Somehow RVS was Andhra Pradesh, India
forgotten and there was no mention of it in the anatomy or surgery Corresponding Author: Mohan Rao Voruganti, Department of General
books. Majority of the data on RVS have come from the works of Surgery, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and
2
Reynaud, Gans, and Couinaud on the liver anatomy. In 1955, Gans Research Foundation, Chinnaoutpalli, Andhra Pradesh, India, Phone:
in his doctoral thesis described RVS as an extension of porta hepatis +91 9848121153, e-mail: mohanraovoruganti@outlook.com
3
but he did not elaborate on it. Gans incisura, incisura hepatica How to cite this article: Voruganti MR, Mohammed N, Gurrala RC, et al.
dextra were other names for RVS. The present name “Rouviere’s Rouviere’s Sulcus: Anatomy and its Clinical Significance in Laparoscopic
sulcus” was suggested by the French hepatobiliary surgeon Claude Cholecystectomy. World J Lap Surg 2023;16(1):4–7.
Couinaud. Now the name RVS is internationally accepted. With Source of support: Nil
the increasing popularity of laparoscopic cholecystectomy (LC), Conflict of interest: None
the surgical importance of RVS is well recognized in recent times.
Rouviere sulcus accurately determines the plane of the common
bile duct (CBD). The cystic duct and artery lie above and ventral is an extrabiliary landmark in the solid organ liver. It is not affected
to it, whereas CBD lies below to it. This was confirmed by intra- by diseases or retraction of the gallbladder. It is also an important
operative cholangiogram. Rouviere sulcus is visible more clearly landmark for right hepatectomy.
during LC than the open cholecystectomy (OC). There is a wide Rouviere sulcus shows wide anatomical variations. It is present
2
opening of sulcus due to CO pressure and magnified view of RVS in majority of cases ranging from 68 (Zubiar et al., 2009) to 82%.
2
4
with digital cameras and lighting. Hugh et al. were the first to Absent RVS is noted in 10–30% cases in the literature. Length of
recognize the importance of RVS in LC as it shows the correct plane RVS varies from 1 to 5 cm with an average of 3 cm. Width vary from
5
of CBD. They demonstrated the lowest rate of bile duct injury 0.5 to 2 cm averaging 1.1 cm. Depth varies from 0.5 to 2 cm with an
2
(BDI) by dissecting the Calot’s triangle above the RVS. Peti and average of 1.1 cm. The position of RVS is either horizontal, oblique,
Moser described RVS as a lesser known but important landmark or vertical. The horizontal lie is most common and vertical type is
2
6
7
for successful completion of LC and to avoid BDI. Rouviere sulcus least common. Dahmane et al. demonstrated 97% oblique in their
© The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.