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Rouviere’s Sulcus and Critical View of Safety
Table 1: Duration of surgery after identifying RS and may vary, their anatomical structure and certain com-
achievement of CVS monalities exist.
Duration (in min) Percentage of patients These commonalities become obvious through the
20–40 16 numerous cases and procedures reported. Laparoscopic
41–60 40 surgeons must rely on these landmarks and it is crucial in
61–80 23 laparoscopy that detour must be minimized; otherwise,
81–100 16
101–120 5 an unexpected injury is likely to occur. The RS and CVS
are the two landmarks mentioned in preventing bile
duct injury.
Table 2: Length of hospital stay Identification of RS and keeping the dissection ventral
Hospital stay (days) Percentage of cases to it is one of the successful methods to prevent the bile
10
1 80 duct injury. Although recently its significance in lapa-
2 12 roscopic cholecystectomy has been appreciated, there are
3 4 nearly no clinical trials specifying the outcome of surgery
4 or more 4
in terms of bile duct injury. As compared with RS, the role
of CVS in preventing bile duct injury has been largely
Table 3: Incidence of bile duct injury appreciated and studied in preventing bile duct injury.
In our study, we have combined the above-mentioned
Bile duct injury Percentage of cases
Intraoperative 0 landmarks to study their importance in safe execution
Postoperative (leak) 0 of laparoscopic cholecystectomy. The importance of this
combination has not been studied before according to
14
the best of our knowledge. Heistermann et al achieved
of RS and achievement of CVS. Patients were followed CVS in 97 out of 100 patients and cholecystectomies were
up after 1 week and thorough history of any complaint successfully completed with a minor incidence of cystic
was taken, and clinical examination was done (Table 3).
stump leak.
Incidence of bile duct injury was 1%, while the conver-
DISCUSSION
15
14
sion rate was 3%. Yegiyants and Collins also achieved
No other surgery has been so profoundly affected by CVS in 3,000 patients and reported only one bile duct
the advent of laparoscopy as gallbladder surgery, i.e., injury (0.033%) which occurred during the dissection
cholecystectomy. of Calot’s triangle prior to achieving the critical view.
16
In fact, the converse may be more accurate; laparo- Similarly, Avgerinos et al attained CVS in 998 out of
scopic cholecystectomy has been instrumental in usher- 1,046 patients. Five minor bile duct leaks (0.47%) were
ing in the laparoscopic era. Laparoscopic cholecystectomy reported which resolved spontaneously.
16
17
has become the procedure of choice for routine gallblad- Their conversion rate was 2.7%. Likewise, Sanjay et al
13
der removal very rapidly. With increasing frequency got success in achieving CVS in 388 out of 447 patients,
of laparoscopic cholecystectomy, the incidence of biliary all of them completed successfully without any incidence
tract injury has also increased simultaneously. of bile duct injury. In cases where CVS was not achieved,
18
According to the need, many suggestions and modi- they were converted. Rawlings et al studied the impor-
fications have been proposed to prevent biliary tract tance of CVS in 54 patients who underwent single-incision
injury, and one of these is extrabiliary landmarks. Ana- laparoscopic cholecystectomy and reported no incidence
tomical landmarks are the descriptions of neighboring of bile duct injury and came to a conclusion that dis-
structures crucial for identifying proper target tissue for section to obtain the CVS should be the goal in every
dissection and resection. Although individual patients patient (Table 4). In our present study, we laid emphasis

Table 4: Studies showing impact of CVS creation with/without identification of RS
Conversion to open
Series Type of study RS identified CVS created Bile duct injury cholecystectomy
Heistermann et al 14 Case series (n = 100) No Yes (97 cases) 1 minor leak 3%
Yegiyants and Collins 15 Case series (n = 300) No Yes 1
Avgerinos et al 16 Case series (n = 104) No Yes (998 cases) 5 minor leaks 2.7%
Sanjay et al 17 Case series (n = 447) No Yes (388 cases) Nil 13%
Rawlings et al 18 Case series (n = 54) No Yes Nil –
Present study Case series (n = 100) Yes Yes Nil –
World Journal of Laparoscopic Surgery, January-April 2018;11(1):25-28 27