Rouvière’s Sulcus: An External Landmark for Safe Dissection when the Critical View Cannot Be Achieved

Background Intraoperative identification of Rouvière’s sulcus is a proposed strategy to prevent bile duct injuries. Since it marks the plane at which the extra-hepatic ducts lie, limiting surgical dissection ventral to Rouvière’s sulcus should protect the ducts from injury. This is an important adjunct when the critical view of safety cannot be achieved during difficult cholecystectomies. Methods This was an observational study of all consecutive elective laparoscopic cholecystectomies between January 1, 2017 and May 30, 2024. Intraoperatively, Rouvière’s sulcus was identified by surgeons, with correlation by an independent observer. The relationship between the sulcus and the right hepatic pedicle was confirmed by laparoscopic ultrasound. Comparisons were made using SPSS. Results Over 7 years, 356 laparoscopic cholecystectomies were performed, and Rouvieré’s sulcus could be identified in 296 (83.2%) patients. When a well-defined sulcus was present, it correlated reliably to the right portal triad in all cases. However, the reliability of this relationship significantly reduced in the absence of a well-defined sulcus (100% vs 5%; P < 0.0001). Conclusions When present, Rouvieré’s sulcus is a valuable asset to surgeons, who can use it as a landmark for safe dissection planes during cholecystectomies. When a well-defined sulcus is absent, surgeons should employ alternative means of bile duct protection, such as indocyanine green or operative cholangiography.