British Journal of Surgery 1997,84, 1253-1254

Surgical workshop
Rouvikres sulcus: a useful landmark in
laparoscopic cholecystectomy
T . B . H U G H , M . D . K E L L Y and A . M E K I S I C
St Vincents Hospital and St Vincents Clinic, Sydney, Australia
Correspondence to: Dr T B. Hugh, St Vincents Clinic, 438 Victoria
Street, Darlinghurst, New South Wales 2010, Australia

Laparoscopic cholecystectomy is now the preferred

treatment for gallbladder stones in most major centres.
However, the laparoscopic perspective and twodimensional image of video laparoscopy require the
surgeon to use new cues and landmarks, unfamiliar in
open cholecystectomy, in order to identify biliary anatomy
accurately. These difficulties are reflected in the reported
increased risk of bile duct injury in laparoscopic compared
with open cholecystectomy.*.
Various operating strategies have been described to
minimize the risk of bile duct injury during cholecystectomy-7, but a common problem in difficult cases is
accurate identification of the position of the common bile
duct (CBD).
An anatomical landmark is described, which aids in
recognition of the plane of the CBD at laparoscopy.
In 1924, Henri Rouvibre described a 2-5-cm sulcus,
running to the right of the liver hilum anterior to the
caudate process, and usually containing the right portal
triad or its branches4. Couinauds drew attention to the
value of the sulcus in providing access to right portal
structures in right-sided liver resections and indicated that
it was present in 73 per cent of subjects.
The sulcus was recognizable, being either fully (n = 41)
or partially ( n = 3 7 ) open, in 78 of 100 consecutive
patients undergoing laparoscopic cholecystectomy in this
hospital. The sulcus was found to indicate the plane of the
CBD accurately in each case. An operative cholangiogram
was obtained in 67 of the 78 patients in whom a sulcus
was present, providing confirmation of the biliary
anatomy.
The authors have found the sulcus to be a useful
indicator of the appropriate site to commence dissection
of the hepatobiliary triangle in laparoscopic cholecystectomy.

Surgical technique
The sulcus is best seen if grasping forceps are placed on the neck
of the gallbladder, which is then retracted upwards and towards
the left, so that the posterior aspect of the hepatobiliary triangle
is exposed. If present, the sulcus is seen running to the right of
the hilum (Fig. I). In some patients, the lips of the sulcus are
partially fused, with only a small cleft visible laterally.
The sulcus indicates reliably the plane of the CBD; dissection
may be started safely by division of the peritoneum immediately
ventral to the sulcus and continued in a triangle bounded by the
liver surface, the neck of the gallbladder and the plane of the
sulcus (Fig. 2). Even if the bile duct is tented upwards by the
traction that has been exerted on the gallbladder, dissection will
be safely ventral to the plane of the duct. Posterior branches of

Paper accepted 4 January 1997

0 1997 Blackwell Science Ltd

Fig. 1 Partially fused Rouvikres sulcus; the white line of fusion

(arrowed) indicates the plane of the sulcus. Dissection ventral to
this plane is ventral to the main bile ducts

Fig. 2 Diagram of a fully open Rouvieres sulcus, indicating the

triangle within which dissection may safely be commenced in a
plane ventral to that of the common bile duct

the cystic artery, or a caterpillar hump hepatic artery, may lie in

the area of dissection and must be identified with care.
Once a plane has been opened posteriorly, attention may be
turned to the anterior dissection, using the posterior landmarks
as a guide. The anterior and posterior dissections can then be
made to meet, thus opening the hepatobiliary triangle
completely.

Utilizing these anatomical principles, the authors have

now completed 750 consecutive laparoscopic cholecystectomies, including patients with acute cholecystitis and cases
operated on by trainees, without bile duct injury.

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1254 T. B. H U G H , M. D. K E L L Y and A. M E K I S I C

References
1 Deziel DJ, Millikan KW, Economou SG, Doolas A, Ki S-T,
Airan MC. Complications of laparoscopic cholecystectomy: a
national survey of 4292 hospitals and an analysis of 77604
cases. Am J Surg 1993; 165: 9-14.
2 Moossa AR, Easter DW, Van Sonnenberg E, Casula G,
dAgostino H. Laparoscopic injuries of the bile duct. A cause
for concern. Ann Surg 1992; 215: 203-8.

3 Cox MR, Wilson TG, Jeans PL, Padbury RTA, Toouli J.

Minimizing the risk of bile duct injury at laparoscopic
cholecystectomy. World J Surg 1994; 18: 422-7.
4 Rouvikre H. Sur la configuration et la signification du sillon du
processus caudC. Bulletins et Memoires de la Societk
Anatomique de Paris 1924; 94: 355-8.
5 Couinaud C. Surgical Anatomy of the Liver Revisited. Paris:
C Couinaud, 1989.

0 1997 Blackwell Science Ltd, British Journal ofsurgery 1997, 84, 1253-1254