Role of Rouviere's sulcus in identification and dissection of Calot's triangle during Laparoscopic Cholecystectomy

Document Type : Original Article


1 General Surgery, Faculty of Medicine, Al-Azhar University, Cairo Branch

2 Professor of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo Branch

3 Lecturer of General Surgery, Faculty of Medicine, Al-Azhar University, Cairo Branch


Background -
One of most common surgical technique applied overall the world is laparoscopic cholecystectomy due to the high features instead of another surgical techniques. Furthermore; it is represents as the main technique for gallstones treatment; however the incidence of bile-duct injury still higher than that of open cholecystectomy. Various surgical procedures and principles have been proposed to reduces bile duct injury.

Aim - to determine the frequency and the type of Rouviere’s sulcus and its importance as landmark during laparoscopic cholecystectomy.

Patients and Methods - This prospective study included hundred-patients who had symptomatic gallstone disease and underwent laparoscopic cholecystectomy in Al Azhar Universty Hospitals and Ahmed Maher Hospital.

Results - Our results revealed that, regarding the indications for cholecystectomy, the most common indication in the study participants were symptomatic gall stones in 36 (36%) of participants followed by acute cholecystitis in 29 (29%) participants and biliary pancreatitis in 16 (16%) participants.

Conclusion - Rouviere‘s sulcus was re-present in (76%) of total cases. It is an easily identifiable anatomic feature for secure laparoscopic cholecystectomy.



Laparoscopic surgery is known as the standard procedure in stone disease. Whilst; laparoscopic cholecystectomy is correlating with more biliary, vascular and visceral complications than when compared with open cholecystectomy. 1

The prevalence of ductal lesions in laparoscopic-cholecystectomy is close to 0.5%. In spite of advances in laparoscopic cholecystectomy, bile duct damage carry on to occur and there has been no reduction in mortality. 2

Most duct injuries expected to performed due to mis-re-cognition of the bile duct anatomy due to misinterpretation and/or lack of understanding of the anatomical. Specific internal and external anatomy can help surgeons, specifically in difficult situations.3

By using the well-described anatomical features, in combination with other well-documented methods, such as the triple Calut incision to ensure critical safety, the surgeon will reduce the risk of damage to the bile duct, especially if it is acutely inflamed. Another unknown known endoscopic term used for cholecystectomy is Rovier's-sulcus. The Rouvière-sulcus is another distinctive device that can be used to block the bile duct. 3&4

 Rovier, a French surgeon have been described Rovier’s sulcus  related to his name which is 2- to 5-cm groove that extends from the right anterior hilum of the liver to the caudal lobe. The decent trinity contains one or more of its branches. 4 Common sulcus accurately determines the level of the channel. This external path is always a sign of the surface of life and there is no unstudied pathology. 5

The aim of this study was to determine the frequency and the type of Rouviere‘s sulcus and its importance as landmark during laparoscopic cholecystectomy.


In this prospective study hundred patients were enrolled diagnosed with gallstone disease and underwent laparoscopic cholecystectomy in Al Azhar Universty Hospitals and Ahmed Maher Hospital.

Symptomatic gallstone disease and candidate for laparoscopic cholecystectomy, early acute cholecystitis within 3 days, chronic non-calcular cholecystitis provides to be nonfunctioning, ages Eligible for Study: Above 14 years and both sexes were included. Pregnant women, high risk for general anasethia, signs of gall bladder perforation as abscess, peritonitis, fistula, suspected malignancy, bleeding disorder , blood coagulation dysfunction, severe abdominal cavity adhesion and end stage liver disease with portal hypertension and severe coagulopathy were excluded.

All Patients were subjected to the Following: complete History; Full clinical Examination: general examination and local abdominal examination. Laboratory Investigations including: Complete blood picture, serum electrolytes, blood urea, serum creatinine, fasting blood sugar, liver function tests and coagulation profile, cross match and blood group are requested. Imaging Studies: Ultrasound abdomen and pelvis.

After written informed consent for laparoscopic cholecystectomy, the operative data were recorded including the absence or presence of adhesion, the absence or presence of Rouviere‘s sulcus, dissection of the Calot‘s triangle was done at or just above the level of Rouviere‘s sulcus with identification of the cystic artery and cystic duct. Post operatively the complications were recorded including biliary leake, obstructive jaundice or evidence of clipping or biliary tree injuries.

Key results were tabulated and analyzed by suitable statistical methods using the computer program Statistical Package for the Social Sciences (SPSS) version 16 software. Categorical data were presented as number and percentages while quantitative data were expressed as mean ± standard deviation (SD), and range and percentages.





The age of the study cases ranged from 23 to 70 years old with a mean value of 47.74 ± 14.18 years. 38 (38%) cases were males while 62 (62%) were females.


Study participants (n =100)

Age (years)

Mean ± SD

47.74 ± 14.18


23 - 70




38 (38%)


62 (62%)

Table 1: Baseline characteristics of the study participants


















Fig. 1 : Age of the study participants


Fig. 2: Gender of the study participants



Study participants (n =100)





Indications of cholecystectom y

Symptomatic gallstone

36 (36%)

Acute cholecystitis

29 (29%)

Biliary pancreatitis

16 (16%)

Asymptomatic gallstone

5 (5%)

CBD stones

7 (7%)


4 (4%)

Other indications

3 (3%)

Presentation with acute attack


58 (58%)


42 (42%)

Table 2: Preoperative data of the study participants


Fig. 3: Indications of cholecystectomy in the study participants


Fig. 4: Presentation with acute attack in the study participants

Regarding intraoperative data, adhesions were present in 11 (11%) cases, sulcus was visible in 76 (76%) cases. Sulcus was open type in 43 (43%) cases, closed in 13 (13%) cases, slit on 11 (11%) cases, and scar type in 9 (9%) cases. Calot dissection was done above in 69 (69%) cases and at or below in 31 (31%) cases, biliary injury, blood loss occurred in 2 (2%) and 8 (8%) cases respectively. In all cases, only 10 (10%) were converted to open cholecystectomy in the form of technical problem (3 cases). Severe adhesion and inflammation (4 cases).distorted anatomy (2 cases) and biliary injury (1case)


Study participants (n =100)




11 (11%)

Not present

89 (89%)

Rouviere’s Sulcus


76 (76%)

Not visible

24 (24%)


Type of Rouviere’s Sulcus

Open sulcus type

43 (43%)

Closed sulcus type

13 (13%)

Slit type

11 (11%)

Scar type

9 (9%)


Calot dissection


69 (69%)

At or below

31 (31%)


Biliary injury


2 (2%)


98 (98%)


Blood loss


8 (8%)


92 (92%)

Conversion to open


10 (10%)


90 (90%)

Table 3: Intraoperative data of the study participants


Fig. 5: Presence of adhesions in the study participants


Fig. 6 : Presence of sulcus in the study participants


Fig. 7: Calot dissection in the study participants



Fig. 8: Biliary injury in the study participants



Fig. 9: Blood loss in the study participant



Fig. 10: Conversion to open cholecystectomy in the study participants


Study participants (n =100)




4 (4%)

Not present

96 (96%)


Biliary leak


3 (3%)

Not present

97 (97%)

Postoperative wound infection


7 (7%)

Didn’t occur

93 (93%)




74 (74%)

Not present

26 (26%)


Table 4: Postoperative data of the study participants


Fig. 11: Presence of collection in the study participants


Fig. 12: Biliary leak in the study participants


Fig. 13: Postoperative wound infection in the study participants


RS visible (n =76)

RS not visible (n =24)

P value

Duration of operation (minutes)

Mean ± SD

107.76 ± 25.14

122.75 ±





75 – 180

100 - 184

Length of hospital stay (days)

Mean ± SD

1.48 ± 0.53

2.75 ± 1.15




1 – 3

1 – 5

Table 5: Duration of operation and hospital stay in the study participants


Fig. 15: Duration of operation in patients with or without visible RS


Fig. 16: Length of hospital stay in patients with or without visible RS


This prospective study included hundred patients with symptomatic gallstones who underwent laparoscopic cholecystectomy at Al-Azhar University and Ahmed Maher Hospital.

The age of the participants in our study ranged from 23 - 70 years, with a mean of 47.74 ± 14.18 years. 99 patients were included in the study for one year. In laparoscopic cholecystectomy, Jha et al. 6 that the age of onset of cholelithiasis was mainly in the fourth decade of life (33.6%).

Kumar et al.7 found that middle-aged patients were 41.56 ± 14.27 years old and had middle-aged uncomplicated gallstones. The highest reported frequency of Rovier ridges (GOR > 90%) was reported by Kumar et al.7 who attributed this to excellent carbon dioxide production and image quality.

Consequently, Kumar et al. 7 showed that the overall incidence of biliary tract lesions (BIDs) at assessment was 1 in 230, equivalent to 0.4%, and the incidence of biliary tract lesions during laparoscopic cholecystectomy indicated dissection of the abdominal cavity in the SR representatives.

Sachdeva et al.8, where the mean age increased to 41.5 ± 15.4 years in accordance with our reults.

Our data are from Randhawa et al. 9 Most gallstone patients were women, the relationship between women and men Rosen and Brody 10 are working on choleithiasis patients.

Saldinger and Bellorin-Marin11 female/male ratio 2.43:1.1.56:1 in gallstones, however; In a study by shinde and pandit 12 female had higher preponderance of gall stone with female to male ratio of 1.56:1. Sridhar et al.13 Estrogen promotes the excretion of cholesterol into the bile, resulting in excess bile.

High density, high quality, high density, high density, high density, high strength (76%). The splint opened in 43 (43%) cases, closed in 13 (13%) cases, broke in 11 (11%) cases and scored 9 (9%) cases. Anterior callus opening was performed in 69 cases (69%) and in at least 31 cases (31%). These are Tapa et al. 14 cases of early Rovier's disease were found in 75% of the patients, Mohamed et al.15 Fifteen of them described Rover depression in 73% of the cases.

According to a study by Hugh et al.16 The number of shells that can be withdrawn from the slurry slot 402 is 319 (79.3%) and 80 (20.7%). In 221 cases (54.9%) the splint was open and in 98 cases (24.4%) the splint was scarred.

In addition, Antoniou et al.17 in their study of 160 patients were able to visualize the Rouvière sulcus in 109 (68.13%) patients during laparoscopic cholecystectomy. Rouvière's open type sulcus was observed in 48 patients, while 61 had a fused sulcus type and Dubhashi et al. 18 whose aim was to obtain the frequency and type of Rouvière's groove.

Other researchers have reported different frequencies of the presence of Rouvière's sulcus in their research. Dubhashi et al. 18 out of 78%, Dahmane et al. 19 in 82% and Danny A. Sherwinter, 20 noted a furrow in 68.13% of cases.

Kalra et al. 21 reported that Rouvière's groove was present in 63 study participants. It was found to be above the CBD level in 50 (79.36%) patients and above the CBD line at the sulcus level in 11 (17.46%) and 2 (5.97%) patients.

It has been suggested that all dissections should be kept above the level of this sulcus to avoid damage to the common bile duct. 22

According to Elwan 23, the aim was to explore the critical view of safety and sulcus Rouvière as extrahepatic landmarks and their usefulness in preventing damage to the common bile ducts. They reported that the open type was found in 175 (58.3%) patients and the closed type in 118 (39.3%) patients. The sulcus was absent in seven (2.3%) patients. Elwan 23 reported conversion to open cholecystectomy in two (0.7%) patients due to severe adhesions that could not be safely ruptured laparoscopically. There were no major intraoperative or postoperative complications.

A recent meta-analysis of 23 anatomical or laparoscopic studies found an overall incidence of Rouvière's sulcus of 83% in 49 patients (98%) in their study.

At one facility, 1,046 patients underwent laparoscopic cholecystectomy from 2002 to 2007, 998 of which included the safety-critical eye. The conversion rate for open cholecystectomy was 2.7%. In addition, at a single facility, 1,046 patients underwent laparoscopic cholecystectomy from 2002 to 2007, using safety-critical vision in 998 cases. There were five gall leaks that were resolved with conservative measures. 24

In addition, Lockhart S and Singh-Ranger et al 25 reported that the duration of admission in the visible SR group was significantly shorter than in the non-visible SR group. The shorter hospital stay in the visible SR group can be attributed to a shorter operation time, less dissection and less need for the placement of drains in this group.


Rouviere‘s sulcus was present in (76%) of our cases. It is an easily identifiable anatomical landmark for safe laparoscopic cholecystectomy.



    1. Cheruiyot, I., Nyaanga, F., Kipkorir, V., Munguti, J., Ndung'u, B., Henry, B., Tomaszewski, K. The prevalence of the Rouviere's sulcus: A meta‐analysis with implications for laparoscopic cholecystectomy. Clinical Anatomy. 2021; 34(4), 556-64.
    2. Mischinger, H. J., Wagner, D., Kornprat, P., Bacher, H., & Werkgartner,  G.  (2020).  The  ―critical  view  of  safety  (CVS)‖ cannot be applied—What to do? Strategies to avoid bile duct injuries. European Surgery. 2020; 4(9):1-7.
    3. Lockhart,  Stuart,  and  Gurpreet  Singh-Ranger.  ―Rouviere‘s  sulcus- Aspects of incorporating this valuable sign for laparoscopic cholecystectomy.‖ Asian Journal of Surgery. 2018;41(1)1-3
    4. Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg. 2019;11(2):62-8
    5. Bahram M, Gaballa G. The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones. Int J Surg. 2010;8(5):342-5.
    6. Jha AK, Dewan R, Bhaduria K. Importance of Rouviere's sulcus in laparoscopic cholecystectomy. Ann Afr Med. 2020;19(4):274-7.
    7. Kumar A, Shah R, Pandit N, Sah SP, Gupta RK. Anatomy of Rouviere‘s sulcus and its association with complication of laparoscopic cholecystectomy. Minim Invasive Surg. 2020;2020:3956070.
    8. Randhawa HP, Ashwani K. Preoperative prediction of difficult laparoscopic cholecystectomy: A scoring method. Indian J Surg. 2009;71:198–201.
    9. Rosen M, Broody F. Predictive factors for conversion of laparoscopic cholecystectomy. Am J Surg. 2002;184:254–7.
    10. Saldinger PF and Bellorin-Marin OE. Anatomy, Embryology, Anomalies, and Physiology of the Biliary Tract. Shackelford's Surgery of the Alimentary Tract, 2 Volume Set. Elsevier. 2019; 1249-66.
    11. Shinde J, Pandit S. Innovative approach to a frozen Calot‘s triangle during laparoscopic cholecystectomy. Indian J Surg. 2015;77(6):554e557.
    12. Sridhar P, Arole V, Bharambe V and Sonje P.A study of anatomy of Calot‘s triangle and its clinical significance. Pulsus J Surg Res. 2018; 5(2): 45-9.
    13. Thapa PB, Maharjan DK, Tamang TY, Shrestha SK. Visualisation of Rouviere's Sulcus during Laparoscopic Cholecystectomy. JNMA J Nepal Med Assoc. 2015;53(199):188-91.
    14. Muhammad Z, Lubna H, Farzana M, Masoom RM, Mehmood AK, Quraishy MS. "Rouviere‘s sulcus: a guide to safe dissection and laparoscopic cholecystectomy." Pak J Surg .2009; 22(2): 119-21.
    15. Hugh TB, Kelly MD, Mekisic A. Rouviere′s Sulcus: A useful landmark in laparoscopic cholecystectomy. Br J Surg. 1997;84:1253–4.
    16. Antoniou A, Raynaud P, Cordi S, et al. Intrahepatic bile ducts develop according to a new mode of tubulogenesis regulated by the transcription factor SOX9. Gastroenterology. 2009;136:2325–33.
    17. Dubhashi, S.P. & Jenaw, R. & Gupta, S.. Rouviere's sulcus as an anatomical landmark for safe laparoscopic cholecystectomy. Journal of Krishna Institute of Medical Sciences University. 2018; 7(3): 65- 9.
    18. Dahmane R, Morjane A, Starc A. Anatomy and surgical relevance of Rouviere's sulcus. Scientific World Journal. 2013;2013:254-87.
    19. Danny A Sherwinter, MD. Laparoscopic Cholecystectomy Technique. 2022; 5(2): 120 -31.
    20. Kalra A, Yetiskul E, Wehrle CJ, et al. Physiology, Liver. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2022; 403 - 30.
    21. Zambirinis, C. P., & Allen, P. J. Anatomy of the Pancreas and Biliary Tree. In Surgical Diseases of the Pancreas and Biliary Tree. 2018; 9(2): 33 - 40.
    22. 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
    23. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the ‗critical view of safety‘ technique. J Gastrointest Surg. 2009; 13:498–503.

    8.     Sachdeva S., M. Ansari, A. Anees, Z. Khan, and N. Khalique, ―Lifestyle  and  gallstone  disease:  scope  for  primary  prevention,‖ Indian Journal of Community Medicine. 2011; 36(4):263– 7.

    Lockhart S, Singh-Ranger G. Rouviere's sulcus—Aspects of incorporating this valuable sign for laparoscopic cholecystectomy. Asian journal of surgery. 2018; 41(1):1-3.