Page 6 - World Journal of Laparoscopic Surgery

Rouvier’s Sulcus: Anatomy and its Clinical Significance
dissection of cadaveric livers. Rouviere sulcus is classified as (1) open, Table 1: Type of sulcus
(2) closed, (3) slit, and (4) scar. Open sulcus is continuous with the Type of sulcus No. of patients Percentage
porta hepatis at its medial end and has measurable dimensions of Open 77 72.6
length, breadth, and depth. Branches of right hepatic pedicle are
visible in it. Closed sulcus has a closed medial end and partly visible Closed 14 13.2
right hepatic pedicle. Length, breadth, and depth can be measured. Slit 11 10.4
Slit sulcus is a shallow sulcus with no visible right hepatic pedicle. Scar 04 03.8
Only length can be measured. The breadth and depth are barely Total 106 100
measurable. Scar sulcus appears as a white scar that is completely
fused. Some authors combine both open and closed sulci together
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as deep sulcus. Rouviere sulcus contains right portal pedicle or Table 2: Direction of sulcus
its branches. It contains right posterior sectoral pedicle in 70% Direction No. of cases Percentage
cases. The vein to segment VI, anterior sectoral pedicle, or cystic Horizontal 74 69.80
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vein is seen in 25%, 5%, and 18% of cases, respectively. Majority Oblique 31 29.25
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of knowledge on RVS comes from the works of Dahmane et al. on Vertical 01 00.95
cadaveric livers. The surgical importance of RVS—the cystic duct Total 106 100
and the artery lie above the plane of RVS and the CBD lies below
it, making RVS is an established anatomical landmark for a safe
cholecystectomy. In LC it is easy to see the sulcus when gallbladder Table 3: Measurements of sulcus
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is pulled medially toward umbilical fissure. Hugh et al. stressed that Length in mm Breadth in mm Depth in mm
during LC, the RVS is the first landmark from where the dissection Type of RVS (average) (average) (average)
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of the Calot’s triangle should start. Peti and Moser also stressed Open 24–42 (31) 8–15 (11) 6–12 (10)
the same for conduct of safe cholecystectomy and to avoid BDI. The Closed 18–28 (22) 6–11 (8) 4–9 (7)
importance of RVS is also stressed in the Tokyo guidelines (2018) Slit 10–16 (13) 2–4 (3) 0
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for management acute cholecystitis. They suggest that in acute Scar 42–87 (58) 0 0
cholecystitis, the base of segment IV and the roof of RVS should be
used as anatomical landmarks, and any surgical procedures during
cholecystectomy should be performed above the line connecting in difficult cases. Postoperative complications of bleeding and
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these two landmarks. This line is known as R4U line, which is drawn bile leak were noted
from the roof of RVS and the base of segment IV to the umbilical
fissure. The zone above this line is a safe zone for LC and below the results
R4U line is unsafe. When RVS is absent, an imaginary line is drawn • Age distribution: Age in this study varied from 18 to 73 years.
from umbilical fissure across base of segment IV and extended to Mean age was 43.72 years. Maximum incidence is in 4th decade
the right across the hepatoduodenal ligament to mark a safe zone. with 32% and 5th decade with 28%. The youngest was 18 years
The dissection of the hepatocystic triangle must be performed in old girl and the oldest patient was a 73 years old man.
the safe zone to achieve the critical view of safety and avoid BDI. • Sex: Females (83) dominate males (47) with F:M ratio of 64:36.
The objective of this work is to study incidence and morphology • Incidence of RVS: Rouviere sulcus is seen in 106 (81.5%) cases
of RVS and its importance in LC. and absent in 24 (18.5%) cases. In majority of cases (84 of 106),
it is seen on retraction of infundibulum to the left. In 22 cases,
MAterIAls And Methods RVS was visible after the separation of adhesions.
A prospective study of RVS was conducted in the Department • Type of sulcus: Open type is most common with 72.6% and scar
is least with 3.8% (Table 1).
of General Surgery of a tertiary care hospital from March • Direction of sulcus: Horizontally directed RVS is most common.
2021 to June 2022. A total of 130 patients were included in Vertical directed sulcus is rarely seen (Table 2).
this study. All patients with symptomatic gallstone disease • Measurements of RVS: See Table 3.
were thoroughly investigated with routine hematological • Pre-operative diagnosis: Cholelithiasis was found in 93 (71.5%)
investigations, ultrasonogram (USG), liver function test (LFT), and cases, cholecystitis in 23 (17.7%), choledocholithiasis in 11 (8.5%)
other needed investigations. Laparoscopic cholecystectomy was (taken up after ERCP stone removal and stenting), and biliary
conducted under general anesthesia. A standard 4-port LC was pancreatitis in 3 (2.3%) cases.
done. After retracting fundus of GB toward the right shoulder, • Difficulty in LC: NASSER Classification. 103 (79%) cases are simple
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the infundibulum of GB is retracted to the left of the patient to in grades 1 and 2, 27 (21%) cases are difficult Calot’s in grades 3
see RVS. Following data are noted: presence or absence of RVS, and 4.
type, direction and measurements were made using marked • Critical view of safety achieved using RVS as landmark.
feeding tube. Intraoperative difficulty in LC is graded according
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to the modified Nassar scale. Laparoscopic cholecystectomy In 118 cases, CVS was achieved using RVS and R4U line as a landmark.
was completed with RVS as the landmark and keeping above it These 16 cases were with absent RVS. In 12 (9%) cases, CVS could
to achieve CVS. When RVS is absent imaginary R4U line is used not be achieved due to edema, dense adhesions, and fibrosis in
as the landmark. In cases of difficult cholecystectomy, where the Calot’s triangle. Eight of these cases are acute cholecystitis,
CVS is not achieved, after consultation with another surgeon four cases were with fibrosed Calot’s triangle. Bailout procedures
bail out procedures were undertaken with OC or subtotal were taken up after a consultation with a second surgeon. Of the
cholecystectomy (STC) above R4U line. Drains were used only 12 cases, 4 cases were converted to OC. Eight cases were managed

World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023) 5