Page 7 - World Journal of Laparoscopic Surgery

Rouvier’s Sulcus: Anatomy and its Clinical Significance
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with STC using RVS or R4U as landmark and completing the due to inclusion or exclusion of scar type in their studies. In a
procedure in the safe zone. Out of eight STC, two were fenestrating meta-analysis of 23 anatomical or laparoscopic studies, Cheruiyot
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type and six were reconstituting type. et al. reported an overall incidence of 83%. Our study with 81.5%
is at par with majority of reports. It is well preserved in cases of
coMplIcAtIons acute cholecystitis. Sometimes it is visualized after adhesiolysis.
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Bleeding Dahmane et al. studied the contents of the RVS in their autopsy liver
specimens. They noted the right portal pedicle in majority of cases.
Bleeding was seen in eight cases, resolved with medication, and Rouviere sulcus has wide morphological variations. It is described
blood transfusion was needed in two cases. Mostly seen in difficult as open, closed, slit, and scar types. some authors described open
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GB with conversion to OC. and close type together as deep sulcus. Our series show 72% and
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Bile Leak 13% of open and closed sulcus, respectively. Direction is horizontal
in majority of cases (74%). Vertical sulcus was seen in one case. The
No major BDIs were seen. Bile leak was observed in five cases. type, measurement, and the direction of the sulcus vary widely.
Evaluation of these five cases with ERCP revealed slipped clips from When the fundus of GB is pulled upwards and to right shoulder
the cystic duct in one case of LC. Other four cases were a difficult GB the RVS points to the neck of GB where it tapers to form the cystic
where a bailout procedure was done: two cases of STC (fenestrating) duct. An imaginary line drawn from RVS along the base of segment
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and two cases of OC. No BDI was noted here. All cases were relieved IV of the liver to the umbilical fissure is known R4U line. The area
with bile duct stenting. cephalad to the R4U line is considered as a safe zone and caudal to
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Wound Infection it is a danger zone. Dissection of the Calot’s/hepatocystic triangle
is confined to safe zone only, to avoid BDI. When RVS is absent, the
Wound infection seen in 12 cases, treated with drainage and R4U line is drawn at the base of segment IV and extended across
dressings. the hepato-duodenal ligament. Hugh et al. were the first to
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recognize the importance of RVS in LC as it shows the correct plane
dIscussIon of CBD. They demonstrated lowest rate of BDIs by dissecting Calot’s
Bile duct injury is a serious complication of LC associated with triangle above the RVS. Peti and Moser described RVS as an important
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morbidity, mortality, and loss of quality of life for the patient. This landmark for successful completion of LC and to avoid BDI. The
one of the major causes of medicolegal litigations. The prevention of importance of RVS is emphasized in the Tokyo guidelines 2018 for
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BDI is an integral aspect of LC. Misinterpretation of biliary anatomy safe cholecystectomy. They advised to use R4U line as a guideline
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is the major cause of BDI. Other causes are abnormal anatomy, for dissection in acute cholecystitis. In the Delphi consensus on
adhesions, instrumentation, and surgeon’s ability. The classical BDI BDIs more than 80% of the Japanese surgeons agreed that RVS as
occurs when the CBD is mistaken as the cystic duct and cut. The an important landmark to avoid BDI. The Delphi consensus on bile
identification of anatomical structures in laparoscopic surgery is duct injuries during LC also advise the use of safe zone dissection to
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complicated by the fact that these structures exist in a 3D axis, yet the avoid BDs. The SAGES promoted safe cholecystectomy program
proposed some strategies for minimizing BDIs. SAGES advises to
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surgeon’s view is fundamentally 2D. Basically LC is a virtual surgery recognize when the dissection is approaching a zone of significant
performed on an image without tactile sensation for surgeon. The risk and halt the dissection before entering the zone. This is a part
best way to avoid misinterpretation of biliary anatomy is to achieve of adopting a universal culture of safety in cholecystectomy (COSIC).
the CVS. Critical view of safety helps to minimize or eliminate the The zone of significant risk is below R4U line. Brittany Greene et al.
incidence of BDI. However, achieving CVS can be difficult in cases proposed an anatomical landmark, inferior boundary of dissection
with severely inflamed and edematous GB or chronic fibrosed to prevent dangerous dissection in the porta hepatis when a CVS
Calot’s/hepatocystic triangle. Thus, to achieve CVS there is a need may not be immediately achievable. The boundary extends from
for anatomical landmarks to guide the surgeon to start a safe RVS to the peritoneum and fat overlying cystic and hilar plates,
dissection. Even a beginner of LC needs some landmarks to orient near the base of segment IV. Another approach advised is B-SAFE
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himself to a safe dissection. Internal landmarks like cystic lymph landmarks. B-SAFE stands for the bile duct, the sulcus of Rouviere,
node and elephant trunk sign, where infundibulum narrows to the left hepatic artery pulsations, the umbilical fissure, and the
form the cystic duct are advocated. But these land marks are not duodenum (enteric). In our series, we did not have any major BDI.
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useful in cases of acute cholecystitis with edema and inflammation Bile leaks were seen mainly in difficult bailout cases. Conversion to
or chronic cholecystitis with dense fibrosis. Rouviere sulcus is a OC was done early in the study. Only two of four open conversions
safe but less known extrabiliary landmark for LC. Though RVS could be completed and other two were operated with open STC.
was mentioned by Henri Rouviere in 1924, its significance was not Open cholecystectomy does not guarantee the completion of
recognized till the popularization of LC in late 1990s. Reasons being cholecystectomy without BDI. There is additional morbidity and
it is better seen in LC than OC due to distention and illumination of complications of open surgery. The advantage of laparoscopic
digital cameras. Rouviere sulcus is an extrabiliary landmark in solid surgery is lost. So, we started doing laparoscopic STC above R4U
organ, liver, which is not affected by the inflammatory scarring line. Fenestrating type showed bile leak (2 of 3) for which ERCP
of gallbladder. Rouviere sulcus is the first landmark the surgeon was done. Later reconstitution STC was taken up with no bile leaks
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should look for safe LC. Rouviere sulcus is present in majority of post-operatively. In 16 of 24 cases without RVS we could complete
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the cases. Dahmane et al. reported an incidence of 82%, while Peti LC using imaginary R4U line as a guide. In difficult cases RVS guide
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et al. described an incidence of 80%. Singh and Prasad and Kumar us to do a bailout procedure of STC above R4U line. It is suggested
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et al. reported the highest incidence of RVS >90%. Zubiar et al. to remember mnemonic “RANGERS” sign during LC. Rouviere’s at
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reported a lower incidence of 68%. These variations are usually neck of gallbladder eases recognition of structures. This allows the
6 World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023)