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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 49-53

Morphological study of rouviere's sulcus: An important landmark in laparoscopic cholecystectomy and right segmental liver resection


Associate Professor, Department of Anatomy, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Date of Submission06-Sep-2021
Date of Decision18-Dec-2021
Date of Acceptance01-Jan-2022
Date of Web Publication01-Feb-2022

Correspondence Address:
Pushpa Gowda
Department of Anatomy, Kempegowda Institute of Medical Sciences, Banashankari II Stage, Bengaluru - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_121_21

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  Abstract 


Background: Rouviere's sulcus (RS) is a cleft, on the inferior surface of the liver, extending from the caudate process to the right lobe for a variable distance. Cystic duct and artery lie anterosuperior while the common bile duct lies anterior to this sulcus, making it an important landmark in laparoscopic cholecystectomy. Being situated anterior to segment I of liver and having the right posterior portal pedicle as its frequent content, it is an important guide in right segmental liver resection. This study intends to study the anatomy of the RS. Methodology: The present study was done by analyzing 60 formalin-fixed adult livers, for the presence/absence of RS, its morphology and morphometry. Results: RS was present in 49 (81.66%) specimens, it was oblique in 26 (43.33%), transverse in 23 (38.33%) and absent in 11 (18.33%) specimens, RS was classified into three different types - type 1, type 2, and type 3 based on its degree of penetration into the substance of the liver. Type 1, defined as a deep sulcus was present in 37 (61.66%) specimens. Type 2, a slit-like shallow sulcus was observed in 7 (11.66%) and type 3, scar-like sulcus was observed in 5 (8.33%) of specimens. The average length of RS was 2.84 cm, breadth was 0.18 cm and the average depth of the RS was 0.62 cm. Conclusion: RS is an important extra-biliary landmark of the liver, that could easily be visualized during laparoscopic hepatobiliary surgeries and its identification could definitely reduce the risk of bile duct and vascular injuries during these surgeries. Hence, the in-depth knowledge about the anatomy of RS which is less studied and not included in anatomy literature is essential.

Keywords: Bile duct injuries, extra-biliary landmark, laparoscopic cholecystectomy, liver resection, Rouviere's sulcus


How to cite this article:
Gowda P, Udupi S. Morphological study of rouviere's sulcus: An important landmark in laparoscopic cholecystectomy and right segmental liver resection. Natl J Clin Anat 2022;11:49-53

How to cite this URL:
Gowda P, Udupi S. Morphological study of rouviere's sulcus: An important landmark in laparoscopic cholecystectomy and right segmental liver resection. Natl J Clin Anat [serial online] 2022 [cited 2022 May 22];11:49-53. Available from: http://www.njca.info/text.asp?2022/11/1/49/337040




  Introduction Top


Rouviere's sulcus (RS) (incisura hepatis dextra and Gans incisura) is a cleft present on the inferior surface of the right lobe of the liver. It extends from the caudate process to the right lobe of the liver for a variable length. It may be oblique in orientation or it may be transverse.[1] RS was first described by Rouvier who used it as a landmark and guide in liver resection surgeries, mainly for safe resection of the right lobe of liver. Cystic duct and the cystic artery are related anterosuperior to RS whereas the common bile duct lies anterior to it, in the same plane, this makes the RS an important clinical landmark in laparoscopic cholecystectomy. Its identification helps to avoid injuries to the hepatobiliary ducts. Its identification also helps in location and ligation of cystic artery during these surgeries.[2] RS lies anterior to segment I of liver and the right posterior portal pedicle is a frequent content of RS, this makes it an important clinical landmark in surgeries involving right liver resection.[2]

Laparoscopic cholecystectomy is a common surgical procedure indicated in symptomatic cholelithiasis, cancers related to gall bladder and acute cholecystitis.[1] Laparoscopic surgeries involve the insufflation of CO2 into the peritoneal cavity producing a pneumoperitoneum. The RS opens widely due to the pressure of CO2 insufflation and becomes clearly visible. Enhanced illumination and superior quality of the laparoscopic cameras used during these surgeries in the recent times are other factors which help in clear visualization of the RS during laparoscopic cholecystectomy.[2]

Liver resection surgeries are carried out for secondary metastasis and hepatic malignancy. The functional right lobe of liver is made up of segment V and VIII (anterior segments), segments VI and VII (posterior segments) and segment I (the caudate lobe).[1] The liver is covered by the Glisson's capsule. This fibrous Glisson's capsule encircles the portal vein, the bile duct and the hepatic artery, called the Glisson's pedicle at the hilum of the liver (porta hepatis). The Glisson's pedicle divides into left pedicle, right anterior pedicle, and right posterior pedicle in the hilum of liver, these pedicles further divide into tertiary branches within the substance of the liver.[1] During the segmental resection of the right lobe of liver, while resecting segment V, cholecystectomy is carried out at first, anterior to the RS, to avoid injury to right posterior pedicle, which is a frequent content of RS. This helps elective vascular control while carrying out segmentally oriented right liver resection.[3] The RS is lesser-known, less studied, but an important anatomical landmark which can help avoid injuries to the hepatobiliary ducts and vessels during hepatobiliary surgeries.[4] RS is not described in detail in anatomy textbooks. It is not described in detail even in surgical literatures; this makes a detailed study on RS important.[5]

So this study was done to report presence or absence of RS and to evaluate its orientation (oblique or transverse), its morphology and its morphometry.


  Materials and Methods Top


The present study was carried out by analyzing 60 adult liver specimens that were fixed in formalin. These specimens were obtained from the department of anatomy KIMS, Bangalore. The liver specimens used in the study were the ones obtained from the voluntarily donated bodies, during dissection, that were fixed in formalin and were preserved in the department of anatomy. Since it was a cadaveric study, ethical clearance was exempted for the same.

Inclusion criteria

Adult formalin-fixed liver specimens.

Exclusion criteria

Damaged and grossly diseased livers were excluded.

A detailed gross examination of the liver specimens was carried out for the presence/absence of RS. The frequency of the presence of RS was determined by calculating the percentage of the specimen of liver showing the presence of RS in this study.

If present, the direction of RS, whether oblique transverse or vertical was noted. The percentage of each was calculated.

The morphology of RS was studied and RS was classified based on the extent of its penetration into the substance of the liver into:

Type 1 - Deep sulcus, the depth of which is more than 1 millimeter (mm).

Type 1 was subdivided into:

Type 1A - Deep sulcus which continues with the hilum medially.

Type 1B - Deep sulcus which is fused medially, did not continue with the hilum.

Type 2 - Slit like sulcus that is superficial and narrow, without a measurable depth by measuring scale (<1mm).

Type 3 - Scar which appears like a fused line.

Standard morphological classification of the RS is not defined in any literature or in the studies which are available; the type of RS was recorded following the classification stated by Singh and Prasad.[6] All these parameters were recorded and tabulated

Morphometric measurements of RS which were measured, which included its:

  1. Length
  2. Breadth
  3. Depth.


All these parameters were precisely measured for each liver specimen, using measuring scale with centimeter and millimeter markings and the measurements were recorded in centimeters. Flexible cotton thread was used for measuring the length of curved sulcus, which was in turn measured with the same measuring scale.

All these collected data were recorded and tabulated and their averages were calculated.

All parameters studied were compared with the parameters available from previous studies and their relevance analyzed, particularly for liver surgeries such as laparoscopic cholecystectomy and right liver resection, by taking into consideration the findings of laparoscopic surgeons, as mentioned in their studies.


  Results Top


Frequency of Rouviere's sulcus

Out of the 60 liver specimens studied RS was present in 49 (81.7%) and absent in 11 (18.3%) specimens [Figure 1].
Figure 1: Rouviere's sulcus ABSENT

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Direction of Rouviere's sulcus

RS was oblique in 26 (43.33%), transverse in 23 (38.33%) and absent in 11 (18.33%) specimen. None of the specimen showed vertically oriented RS.

Morphology

RS was classified into three different types - type 1, type 2, and type 3 based on its degree of penetration into the substance of the right lobe of liver.

Type 1: Defined as a deep sulcus, the depth of which was more than 1 mm.

Type 1A: Deep sulcus which is open toward the medial side and continues with porta hepatis, was observed in 32 (53.33%) liver specimens, making it the most frequent type in the present study [Figure 2].
Figure 2: Rouviere's sulcus Type 1A. Deep sulcus which is open at the medial end and continues with porta hepatis

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Type 1B: Deep sulcus which is closed at the medial end [Figure 3].
Figure 3: Rouviere's sulcus Type 1B. Deep sulcus which is closed at the medial end

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Type 2: Slit like sulcus, which is superficial and narrow, without a measurable depth by measuring scale (< 1mm) [Figure 4].
Figure 4: Rouviere's sulcus Type 2. Slit like sulcus. Sulcus is present, but not deep

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Type 3: Scar like sulcus [Figure 5].
Figure 5: Rouviere's sulcus Type 3. Scar like sulcus

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The frequencies of these types in the present study are shown in the [Table 1].
Table 1: Morphological types of Rouviere's sulcus (n=60)

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Morphometric measurements

In the slit type and the scar type of sulci (type 2 and 3) the length of the sulcus was measured, while in the deep sulcus (type 1A and 1B), all the three parameters (the length, the breadth, and the depth) were measured. The average length of the RS was 2.84 cm. The average breadth was 0.18 cm. The average depth of the RS was 0.62 cm, with level of error 0.5 mm or 0.01 cm. The maximum and the minimum measurements are shown in the [Table 2].
Table 2: Morphometric measurements of Rouviere's sulcus (n=60)

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  Discussion Top


The detailed knowledge of the anatomy of the liver and biliary system and major advances in imaging techniques have made surgical procedures, both open as well as laparoscopic surgeries easier and safer. Incidences of intraoperative bleeding and postoperative complications have drastically reduced. Variations in anatomical structures and improper identification of the normal anatomical structures during operative procedures are major cause of iatrogenic injuries during laparoscopic surgeries.[2]

RS is a cleft, present on the inferior surface of the right lobe of the liver. It runs obliquely or transversely, extending from the right side of the caudate lobe to the right lobe of the liver for a variable length.[1] It may be open or closed medially. The cystic duct and the cystic artery are related anterosuperior to RS while the common bile duct is present anterior to RS. RS lies anterior to segment 1 of the right lobe of liver and usually contains the right portal pedicle or its branches. This sulcus determines the plane of common bile duct accurately.[2] With all these surgically important structures related to it, it is definitely an important landmark for identifying these important structures during various surgical procedures, especially during laparoscopic surgeries.

In surgical literature as well as in anatomical literature, there are different names for the RS. This sulcus has been described as incisura dextra of Gans, by Reynaud, Coucoravas and Giuly et al.[7] Rouviere was first to name it as “le sillon du processus caudé.” In surgical anatomy, it is called RS[5] This sulcus has not been described in details in medical literatures and a standard classification has not been determined. It has been classified as open and closed types without any further details. Anatomical literatures and books do not include the parameters and morphological description of the RS.

The morphological and morphometric parameters, relations and other important findings of the RS would be helpful to describe the RS and to establish a standard classification for this sulcus, which could be incorporated into medical literature, anatomical as well as surgical. This knowledge could be important and useful to the surgeons while carrying out relevant hepatobiliary surgeries.

In the present study, which was carried out on 60 liver specimens, RS was present in 49 (81.7%) and absent in 11 (18.3%) specimens. Previous studies have determined similar incidence. A study by Dahmane et al.[2] shows the frequency to be 82%, it was 100% in a study by Singh and Prasad[6] and 82.66% in a study by Lazarus et al.[8] The frequency was 79.3% in a laparoscopic study by Al Nazer.[9]

Out of the 60 liver specimens studied, the direction of RS was oblique in 26 (43.33%), transverse in 23 (38.33%) and absent in 11 (18.33%) specimens. None of the liver specimens studied showed vertically oriented RS. The percentage if calculated only for the specimen in which RS was present (49 specimens) it would be oblique in 53.06%, transverse in 46.93% and vertical in 0%. A study by Dahmane et al.[2] mentions the RS to be obliquely oriented in 97% and transversely oriented in 3% of the 40 liver specimens. In the study by Singh and Prasad[6] on 100 livers, oblique RS was found in 30% and horizontal in 70% of the livers. A study by Lazarus et al.[8] shows an equal number of obliquely and transversely oriented RS. Both being 41.33% each, while absent in 7.33%. Inconsistency regarding the direction of RS definitely calls for further studies on the direction of RS on larger sample size.

Morphological types

The different morphological types: Type 1, which was defined as a deep sulcus was seen in 37 (61.66%) specimens, of which, type 1A, deep sulcus open at the medial end and was in continuation with the porta hepatis, was observed in 32 (53.33%) specimens while Type 1B, deep sulcus which is closed at the medial end was observed in 5 (8.33%) of specimens. These findings were similar to study by Lazarus et al. (60.67%),[8] lower than the numbers shown in studies by Dahmane et al. (70%)[2] and by Singh and Prasad (71%).[6] The number were however higher than shown in the laparoscopic study by Al Nazar (54.9%).[9]

Type 2, Slit-like sulcus was observed in 7 (11.66%) of specimen, this is lower than the findings by Lazarus et al. (25.33%),[8] Singh and Prasad (23%)[6] and Al Nazar (24.4%),[9] higher than Dahmaneet al. l (0%).[2]

Type 3, a scar-like sulcus was observed in 5 (8.33%) of specimens in the present study, the findings were lower than that of Dahmane et al.(12%),[2] but higher than that of Singh and Prasad (6%),[6] Lazarus et al. (6.67%)[8] and Al Nazar (0%) [Table 3].[9] Knowledge of the types and frequencies of different types of RS are essential and useful while utilizing RS as a landmark in laparoscopic cholecystectomy and other relevant hepatobiliary surgeries.
Table 3: Morphological types of Rouviere's sulcus (compared with previous studies)

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Morphometry

Majority of the studies on RS have been done on patients during laparoscopic surgeries and they do not mention the measurements as it is difficult to take measurements during surgeries, hence the studies to determine the morphometry of RS have to be preferably done on cadaver liver specimen in which these parameters could be easily and accurately measured.[9],[10],[11],[12] The average length, breadth, and depth of the RS in this study were 2.84, 0.18, and 0.62 cm, respectively. The average length of the RS in this study was similar to the average length of the sulcus in a study by Dahmane et al. (2.8 cm)[2] less than that in a study by Lazarus et al. (3.16 cm)[8] and more than the average length mentioned in the study by Singh and Prasad (2.03).[6] The average breadth of RS in the present study was 0.18 cm, which is similar to the findings by Lazarus et al. (0.18)[2] but less than the findings by Singh and Prasad (0.97).[6] Average depth of RS which was 0.62 cm in this study is similar to that in the study by Dahmane et al. (0.6)[2], but less than the average depth mentioned in the study by Singh and Prasad (0.96)[6] and a study by Lazarus et al. (0.78) [Table 4].[8]
Table 4: Morphometric measurements of Rouviere's sulcus (compared with previous studies)

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More detailed cadaveric studies on RS with large sample size would be helpful to determine and describe the anatomy of RS in details, which in present times of laparoscopic surgeries serves as an important landmark to identify various surgically important structures.[13],[14],[15]

Limitations

RS may not be consistent in extensive cirrhosis of the liver, fatty liver, and other diseases causing scarring of the liver. Its position shape and size may be altered in excessive traction of gallbladder fundus superiorly or in extensive inflammation and adhesions of the gallbladder. To avoid complications during surgeries knowledge of the limitations is equally important as is the knowledge about the important anatomical landmarks.


  Conclusion Top


RS, an important surgical landmark during hepatobiliary procedure is found in 49 (81.7%), oblique in direction (26 specimens, 43.33%) and predominantly are of type 1A type (32, 53.33%) among the specimens (n=60) observed. The morphometric and morphological details of RS is a valuable guidance for the surgical procedures in this region.

Acknowledgment

The authors would like to thank and pay respect to all those kind hearts who have donated their body for research and education purpose without which this work would not have been accomplished. We acknowledge the Head of the Department of Anatomy, for helping us procure the specimens which were required for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jha AK, Dewan R, Bhaduria K. Importance of Rouviere's sulcus in laparoscopic cholecystectomy. Ann Afr Med. 2020;19:274-77.  Back to cited text no. 1
    
2.
Dahmane R, Morjane A, Starc A. Anatomy and surgical relevance of Rouviere's sulcus. ScientificWorldJournal 2013;2013:254287.  Back to cited text no. 2
    
3.
Singh K, Ohri A. Anatomic landmarks: Their usefulness in safe laparoscopic cholecystectomy. Surg Endosc 2006;20:1754-8.  Back to cited text no. 3
    
4.
Machado MA, Herman P, Machado MC. A standardized technique for right segmental liver resections. Arch Surg 2003;138:918-20.  Back to cited text no. 4
    
5.
Peti N, Moser MA. Graphic reminder of Rouviere's sulcus: A useful landmark in cholecystectomy. ANZ J Surg 2012;82:367-8.  Back to cited text no. 5
    
6.
Singh M, Prasad N. The anatomy of Rouviere's sulcus as seen during laparoscopic cholecystectomy: A proposed classification. J Minim Access Surg 2017;13:89-95.  Back to cited text no. 6
    
7.
Reynaud BH, Coucoravas GO, Giuly JA. Basis to improve several hepatectomy techniques involving the surgical anatomy of incisura dextra of Gans. Surg Gynecol Obstet 1991;172:490-2.  Back to cited text no. 7
    
8.
Lazarus L, Luckrajh JS, Kinoo M, Singh B. Anatomical parameters of the Rouviere′s sulcus for laproscopic cholecystectomy. Eur J Anat 2018;22:389-95.  Back to cited text no. 8
    
9.
Al Nazar MK. Rouviere′s sulcus; a useful anatomical landmark for laparoscopic cholecystectomy. IJMRHS 2018;7:158-61.  Back to cited text no. 9
    
10.
Troidl H. Disasters of endoscopic surgery and how to avoid them: Error analysis. World J Surg 1999;23:846-55.  Back to cited text no. 10
    
11.
Hugh TB. New strategies to prevent laparoscopic bile duct injury-surgeons can learn from pilots. World J Surg 2002;132:826-35.  Back to cited text no. 11
    
12.
Machado MA, Herman P, Machado MC. Anatomical resection of left liver segments. Arch Surg 2004;139:1346-9.  Back to cited text no. 12
    
13.
Zubair M, Habib L, Memon F, Mirza MR, Khan MA, Quraishy MS. Rouviere's sulcus: A guide to safe dissection and laparoscopic cholecystectomy. Pak J Surg 2009;22:119-21.  Back to cited text no. 13
    
14.
Rouvière H, Delmas A. Human Anatomy Descriptive. Topographic and Functional, 13th ed. Paris, France: Masson;1991.  Back to cited text no. 14
    
15.
Olsen D. Bile duct injuries during laparoscopic cholecystectomy. Surg Endosc 1997;11:133-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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