|Year : 2022 | Volume
| Issue : 3 | Page : 169-172
A clinically relevant classification of rouvière's sulcus used in the West Indies
Shamir O Cawich1, Michael T Gardner2, Jean-Pierre Louboutin2, Vijay Naraynsingh1
1 Department of Basic Medical Sciences, University of the West Indies Mona, Kingston 7, Jamaica
2 Department of Surgery, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago
|Date of Submission||30-May-2022|
|Date of Decision||03-Jun-2022|
|Date of Acceptance||06-Jul-2022|
|Date of Web Publication||12-Aug-2022|
Shamir O Cawich
Department of Surgery, Port of Spain General Hospital, Port of Spain
Source of Support: None, Conflict of Interest: None
Rouvière's sulcus is an important intra-operative landmark for laparoscopic surgeons. However, there are numerous definitions and classification systems for Rouvière's sulcus in medical literature. We propose a uniform definition and classification system to be used by researchers so that we can make meaningful comparisons of data.
Keywords: Rouvière's sulcus, liver, laparoscopic, anatomic landmark, fissure
|How to cite this article:|
Cawich SO, Gardner MT, Louboutin JP, Naraynsingh V. A clinically relevant classification of rouvière's sulcus used in the West Indies. Natl J Clin Anat 2022;11:169-72
|How to cite this URL:|
Cawich SO, Gardner MT, Louboutin JP, Naraynsingh V. A clinically relevant classification of rouvière's sulcus used in the West Indies. Natl J Clin Anat [serial online] 2022 [cited 2022 Oct 6];11:169-72. Available from: http://www.njca.info/text.asp?2022/11/3/169/353718
Rouvière's sulcus was largely ignored for decades after it was first described in 1924. This was because, in the mid-1990s, open surgeons did not often encounter the sulcus at cholecystectomy [Figure 1]. In contrast, Rouvière's sulcus is well visualized at laparoscopic cholecystectomy because there is better lighting, improved visibility with high-resolution cameras, and more space after insufflation [Figure 2].
|Figure 1: The surgeon's view at open cholecystectomy. Through an incision, the CBD, HP and L are seen, but not Rouvière's sulcus. CBD: Common bile duct, HP: Hartmann's pouch, L: Liver edge|
Click here to view
|Figure 2: The surgeon's view at laparoscopic cholecystectomy. Rouvière's sulcus (arrow) is easily visualized and readily used as a landmark|
Click here to view
In the laparoscopic era, surgeons began to use Rouvière's sulcus routinely as an intra-operative landmark to prevent common bile duct injuries.,,, At this point, many publications began to appear in the medical literature,,,,, and numerous definitions of Rouvière's sulcus were used by different authors.
The original publication by Henri Rouvière, when translated into English, describes a “groove or furrow of the caudate lobe that spanned over one third of the total width of the right lobe of liver.” To give a few examples of the heterogeneity, Dahmane et al. defined Rouvière's sulcus as a “2-3 cm cleft running to the right of the liver hilum anterior to segment I and usually containing the right portal triad or its branches,” Jha et al. defined it as a “2–5 cm fissure on the liver between the right lobe and caudate process” and Lockhart and Singh-Ranger as a “naturally occurring cleft in the right lobe, anterior to Segment 1.” This is not meant to be an exhaustive list but simply to highlight our point that multiple definitions are in use in the medical literature.
To complicate matters further, there is also no consensus on the classification of Rouvière's sulcus. Some authors have classified Rouvière's sulcus as either open or closed based on whether the right hepatic pedicle is easily visible at its floor,,, whether the sulcus is wide throughout its length,, whether it is open toward the right hepatic pedicle or open toward the gallbladder. Some researchers have defined open, fused, or partially fused based on its communication with transverse fissures. Others have introduced terms such as a “sulcus” versus “slit” based on the width of the groove, while others distinguish “sulcus” and “slit” based on the depth of the groove. Others use the term “scar” to differentiate a “white line of fusion” from a slit,, and yet others use the term “scar-like” without stating a clear definition. The multifarious classifications in use make it difficult to meaningfully compare data.
We suggest that it is time for researchers to use a standardized definition that incorporates its clinical significance. In our opinion, Rouvière's sulcus is most useful as an operative landmark during laparoscopic cholecystectomy. Therefore, we propose that the “scar” and “slit” types (excluded by some authors reporting on Rouvière's sulcus),, should be incorporated into the definition. Many authors have included the dimensions, and/or the course,, of the sulcus as a part of its definition, but we do not believe this is appropriate as there are many described variants. Instead, the slit, scar, and other variants can be included as a sub-classification. Most authors have shown that the right hepatic pedicle is consistently associated with Rouvière's sulcus. This has also been the experience in our institution, and for this reason, we believe it should be incorporated into a definition. Based on our observations of anatomical dissections and discussion with surgical colleagues, we propose a clinically relevant definition: “an impression on the visceral surface of the right hemi-liver intimately related to the right portal triad and running for various distances and/or directions into the right hemi-liver.” This definition would include all variants of Rouvière's sulcus.
It is clear that a uniform classification system is also needed. We argue that surgeons must be aware of the morphologic variants to maximize opportunities for Rouvière's sulcus to be used as an intra-operative landmark. Therefore, morphologic subtypes occupy the first tier of our proposed classification [Table 1].
The next most important aspect is the ability to identify the right hepatic pedicle location because this would allow extra-hilar control of the biliary triad during right liver resections. Hence, the second tier of our classification focuses on the medial end of the sulcus, where the portal triad bifurcates. When Rouvière's sulcus communicates freely with the transverse fissure [Figure 2], it is easy to predict the course of the right hepatic pedicle. There seems to be an agreement in the literature to refer to this as an open-type sulcus.,,,,,,,,, Occasionally, the medial end may be covered by a parenchymatous bridge. There is no consensus here, with some authors referring to this as the closed type,,,, fused type,,, parenchymatous-fused type,, partial fused type, or Type 1B. We propose that these terms should be abandoned in favor of “closed type” [Table 1]. The closed type [Figure 3] is important because, even in instances where the right pedicle is not readily visible, multiple authors have shown that the structures are easily exposed with minimal dissection.,,
|Figure 3: Closed type groove: Rouvière's sulcus (arrow) is >5 mm in width and is separated from the transverse fissure (broken line) by a bridge of liver parenchyma|
Click here to view
Occasionally, Rouvière's sulcus is a well-developed, deep, and wide depression with the right hepatic pedicle visible without dissection [Figure 4]. Again, there is no consensus with some authors (sometimes interchangeably) referring to this as a groove,, sulcus,,,,,, or a cleft.,,,,, When the depression is narrow and/or shallow, some authors refer to this as a slit,, or slit-like. However, we have not encountered any publications that actually defined “wide” or “narrow.” In [Table 1], we propose that there should be properly-defined dimensions for “groove” and “slit.”
|Figure 4: Open type, groove. A deep, wide Rouvière's sulcus continuous with the transverse fissure (broken line), with the right hepatic pedicle visible on the floor|
Click here to view
We thought nomenclature would be confusing if one subtype of Rouvière's sulcus was named a “sulcus” and this is why we favored the term groove. A width of >5 mm was chosen as we believed this was clinically relevant when it came to extra-hepatic control of the right hepatic pedicle. For example, the pedicle could easily be identified and accurately controlled with a stapler if the groove was >5 mm in width [Figure 4], but it would require some dissection for a slit <5 mm [Figure 5] and [Figure 6].
|Figure 5: Open type, slit: Rouvière's sulcus (arrow) freely communicates with the transverse fissure (broken line) but is <5 mm wide|
Click here to view
|Figure 6: Closed type, slit: Rouvière's sulcus (arrow) is < 5 mm and is separated from the transverse fissure (broken line) by a bridge of liver parenchyma|
Click here to view
Occasionally, a well-formed groove was absent, but a fibrotic scar could be identified in its place [Figure 7]. We have included this as a type of Rouvière's sulcus because it can still be used as an anatomic landmark at the surgery. When a well-formed groove and/or scar is not present, then Rouvière's sulcus should be considered absent.
|Figure 7: A distinct groove is absent, but a faint white line (scar) can be discerned at the expected location of Rouviere's sulcus|
Click here to view
Based on this classification, examination of 50 cadaveric livers in our institution revealed that Rouvière's sulcus was present in 86% of our population, the majority of which were open-groove subtypes [Table 1].
| Conclusion|| |
Rouvière's sulcus is an important operative landmark. We propose a uniform definition and classification system to be used by researchers so that we can make meaningful comparisons of data.
The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase Humankind's overall knowledge can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rouvière H. The configuration and significance of the sulcus of the caudate process. Bull Mem Soc Anat Paris 1924;94:355-8.
Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ. Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc 2019;33:724-30.
Hunter JG. Exposure, dissection, and laser versus electrosurgery in laparoscopic cholecystectomy. Am J Surg 1993;165:492-6.
Tebala GD, Innocenti P, Ciani R, Zumbo A, Fonsi GB, Bellini P, et al.
Identification of gallbladder pedicle anatomy during laparoscopic cholecystectomy. Chir Ital 2004;56:389-96.
Hugh TB. New strategies to prevent laparoscopic bile duct injury – Surgeons can learn from pilots. Surgery 2002;132:826-35.
Dahmane R, Morjane A, Starc A. Anatomy and surgical relevance of Rouviere's sulcus. ScientificWorldJournal 2013;2013:254287.
Jha AK, Dewan R, Bhaduria K. Importance of Rouviere's sulcus in laparoscopic cholecystectomy. Ann Afr Med 2020;19:274-7.
] [Full text]
Lockhart S, Singh-Ranger G. Rouviere's sulcus – Aspects of incorporating this valuable sign for laparoscopic cholecystectomy. Asian J Surg 2018;41:1-3.
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.
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.
Al-Naser MK. Rouviere's sulcus: A useful anatomical landmark for safe laparoscopic cholecystectomy. Int J Med Res Health Sci 2018;7:158-61.
Abdelfattah MR. The laparoscopic anatomy of rouviere's sulcus. Open Access Surg 2021;14:67-71.
Kim JK, Kim JY, Park JS, Yoon DS. Clinical significance of Rouviere's sulcus during laparoscopic cholecystectomy. HPB 2016;18:515-6.
Bajpayee P, Kanaskar N, Vatsalaswamy P, Manivikar PR. Significance of rouviere's sulcus in hepatobiliary surgery: A cadaveric study. Int J Anat Res 2021;9:8074-8.
Cawich SO, Gardner MT, Barrow M, Barrow S, Thomas D, Ragoonanan V, et al.
Inferior hepatic fissures: Anatomic variants in trinidad and tobago. Cureus 2020;12:e8369.
Elwan AM. Critical view of safety and Rouviere's sulcus: Extrahepatic biliary landmarks as a guide to safe laparoscopic cholecystectomy. Sci J Al-Azhar Med Fac Girls 2019;3:297-301. [Full text]
Cheruiyot I, Nyaanga F, Kipkorir V, Munguti J, Ndung'u B, Henry B, et al.
The prevalence of the Rouviere's sulcus: A meta-analysis with implications for laparoscopic cholecystectomy. Clin Anat 2021;34:556-64.
Lazarus L, Luckrajh JS, Kinoo SM, Singh B. Anatomical parameters of the Rouviere's sulcus for laparoscopic cholecystectomy. Eur J Anat 2018;22:389-95.
Iwanaga J, Singh V, Ohtsuka A, Hwang Y, Kim HJ, Moryś J, et al
. Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors. Clin Anat 2021;34:2-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]