Page 55 - World Journal of Laparoscopic Surgeons

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WJOLS
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10.5005/jp-journals-10033-1328
Rouviere’s Sulcus and Critical View of Safety
RESEARCH ARTICLE

Rouviere’s Sulcus and Critical View of Safety:

A Guide to prevent Bile Duct Injury during
Laparoscopic Cholecystectomy

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1 Malwinder Singh, Atul Jain, Subhajeet Dey, Tanweer Karim, Nabal Mishra, Mansoor Bandey
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ABSTRACT work led to the respectability of laparoscopic surgery in
Context: Laparoscopic cholecystectomy is a commonly per- medical field.
formed minimal invasive surgery. However, its advantages are Laparoscopic cholecystectomy is the “gold standard”
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somewhat tempered due to risk of injury to bile duct. for surgical treatment of symptomatic gallstones.
Minimal invasive surgery holds an important position in
Aims: The objective of the study is to identify Rouviere’s sulcus
(RS) and critical view of safety (CVS) before commencement today’s practice. A large number of surgical procedures
of dissection of Calot’s triangle to prevent injury to bile duct. are performed laparoscopically worldwide with laparo-
scopic cholecystectomy being one of the most commonly
Materials and methods: A series of consecutive 100 patients
admitted in the Department of Surgery in our hospital with practiced.
uncomplicated symptomatic cholelithiasis underwent laparo- The advantages of laparoscopic cholecystectomy over
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scopic cholecystectomy identifying RS and CVS and complica- open surgery are well known. However, along with all
tions (if any) emphasizing bile duct injury. the benefits of minimal invasive procedure came the
Results: The average duration of surgery after identifying inherent drawbacks of performing surgeries in new and
RS and achievement of CVS was 65.30 minutes. There was unfamiliar way. The incidence of biliary tract injuries was
no incidence of bile duct injury after identification of RS and definitely more as compared with open cholecystectomy.
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achievement of CVS. Despite the advancement of laparoscopic cholecystectomy
Conclusion: Rouviere’s sulcus is an important anatomical land- techniques, biliary tract injury still continues to be an
mark for the safe laparoscopic cholecystectomy. Achievement important complication today, although the true inci-
of CVS should be tried in all laparoscopic cholecystectomy. dence is unknown. The most common cause of injury to
Keywords: Bile duct injury, Critical view of safety, Laparoscopic biliary tract is misidentification. The misidentifications
cholecystectomy, Rouviere’s sulcus. are of two main types.
How to cite this article: Singh M, Jain A, Dey S, Karim T, In the first scenario, the common bile duct (CBD)
Mishra N, Bandey M. Rouviere’s Sulcus and Critical View of is mistaken to be the cystic duct and secondly, but
Safety: A Guide to prevent Bile Duct Injury during Laparoscopic less commonly, the identification of an aberrant right
Cholecystectomy. World J Lap Surg 2018;11(1):25-28. hepatic duct as the cystic duct. The direction of trac-
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Source of support: Nil tion of gallbladder has been known to contribute the
appearance of CBD as cystic duct which can lead to
Conflict of interest: None
misidentification injury.
When Hartmann’s pouch is pulled superiorly and not
INTRODUCTION laterally, the cystic duct and CBD get aligned and appear
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Cholelithiasis was first described in 1420 by a Florentine as single structure. The Rouviere’s sulcus (RS) described
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pathologist Antonio Benivenius. The first open chole- by Henri Rouviere in 1924 is now marked as a reference
cystectomy was performed by Carl Johann August Lan- point to guide the commencement of safe dissection. 10,11
genbuch, a German surgeon, at the Lazarus Krankenhaus It is a cleft in liver (Fig. 1) recognizable in >90% of patients,
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on July 15, 1882, whereas laparoscopic cholecystectomy shown by retracting the gallbladder infundibulum
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was first performed in 1987 by Phillip Mouret. His medially. Similarly, a well-delineated junction of cystic
duct with the gallbladder and demonstration of space
between gallbladder and liver clear of any structure
1,2,5,6 Senior Resident, Professor other than cystic artery (safety window or critical view)
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1-6 Department of Surgery, ESI-PGIMSR, ESI Hospital (Fig. 2) is also recommended as an essential step to
Basaidarapur, New Delhi, India prevent biliary tract injury. For the last 15 years, achieve-
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Corresponding Author: Atul Jain, Senior Resident, Department ment of CVS has been adopted by surgeons throughout
of Surgery, ESI-PGIMSR, ESI Hospital, Basaidarapur, New the world for performance of laparoscopic cholecystec-
Delhi, India, e-mail: docatuljain@gmail.com
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tomy. When it was initially described, it was done so
World Journal of Laparoscopic Surgery, January-April 2018;11(1):25-28 25