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

INTRODUCTION

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.

PATIENTS AND METHODS

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.

RESULTS

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.

Table 1: Baseline characteristics of the study participants

Fig. 1 : Age of the study participants

Fig. 2: Gender of the study participants

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)

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

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

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