Rouviere’s Sulcus Anatomy and Its Overall Impact on Operative Time and Complications in Laparoscopic Cholecystectomy: A Longitudinal Observational Study

Abstract

Background:

Rouviere’s sulcus (RS) is widely regarded as an important extra biliary landmark during laparoscopic cholecystectomy (LC), yet its visibility, anatomical variability, and true impact on operative safety remain debated. This study evaluates RS morphology, its incidence of absence, and its influence on operative metrics and complications in a 2-year cohort.

Methods:

A longitudinal observational study was conducted at a single public hospital in the United Arab Emirates, including all elective and emergency LC cases from 2024 to 2025. Electronic medical records and operative videos were reviewed to document RS type, presence or absence, critical view (CV) dissection time, total operative time, and perioperative complications. Statistical analyses included Kruskal–Wallis, Mann–Whitney U, χ²/Fisher’s exact tests, and Spearman correlation.

Results:

Among 130 LC cases, RS was identifiable in 85.4%, with 14.6% absence (95% CI: 9.56–21.70). RS morphology (open, slit, scar, and closed) showed no significant effect on CV dissection or operative time (P > .08). However, RS absence was associated with a significantly longer CV dissection time (median 20 versus 18 minutes; P = .030), while the increase in operative time did not reach significance. Demographic factors and comorbidities showed no association with RS type or visibility. Complications were infrequent (4.6%) and unrelated to RS presence. CV dissection time strongly correlated with total operative duration (ρ = 0.834).

Conclusions:

RS was present in most patients, and its absence modestly prolonged CT dissection but did not significantly affect overall operative time or complication rates. While RS can aid orientation, it should complement rather than replace established safety strategies such as the Critical View of Safety and bailout techniques. Multicenter studies are warranted to further clarify the clinical utility of RS morphology.

Keywords

Rouviere’s sulcus laparoscopic cholecystectomy impact operative time complications

Introduction

Laparoscopic cholecystectomy (LC) technique principally balances the anatomical landmarks of Rouviere’s sulcus (RS), Calot’s Triangle (CT) anatomy, and displaying critical view of safety (CVS).¹ The RS, when visualized during LC, is a hallmark anatomical guide below which the common bile duct (CBD) is usually located, and the recommendation of starting the safe dissection of CT often guides the surgeon to avoid dissecting around the CBD and therefore to avoid CBD injury and aids in cutting short of operative time.^1,2 However, the RS anatomy is not displayed or is absent in 15%–30% cases, and its identification is not always aided in safety and reducing the operative time during LC, as disputed by several studies.^2–4 Our longitudinal single-hospital observational study of over 2 years of cases of LC aim to investigate the different anatomical types of RS, comorbidities, demographical influence on RS type, its absence incidence, its impact on the Critical View (CV) dissection time, overall operation time, and associated complications, with comparative conclusions.

Materials and Methods

The basic case information collected from electronic medical records of the patients along with detailed analysis of the videos of each case for the identification of RS, its type, the time taken for the critical view (CV) dissection from the insertion trocars to the clipping and cutting of the cystic artery (CA) and duct, and overall operative time(from insertion of trocars to the extraction of the gallbladder [GB]), complications and length of hospital stay (LOS) related to the studied cases.

Inclusion criteria

All LC cases were done in both elective and emergency situations at a single public secondary care hospital in the United Arab Emirates (UAE) for 2 years (2024 and 2025).

Exclusion criteria

Cases where the RS area is not displayable due to adhesions and cases that do not have the video recording of the procedure.

Results

A total of 130 consecutive LC cases were analyzed over the 2-year study period. RS morphology, categorized as open, closed, slit, scar, or absent, was determined through systematic operative video assessment, and each case was assigned a single predominant RS type. Continuous variables are presented as mean ± standard deviation or median with interquartile range, and categorical variables as n (%). Group comparisons were conducted using the Kruskal–Wallis H test for analyses involving three or more RS categories and the Mann–Whitney U test for two-group comparisons. Categorical variables were evaluated using χ² or Fisher’s exact tests. The incidence of absent RS was calculated using the Wilson method for 95% confidence intervals. Correlation between CV dissection time and total operative time was assessed using Spearman’s ρ, with a significance threshold of α = 0.05 (two-sided).

Most participants were UAE nationals (38.5%), followed by Omani patients (22.3%). Females represented 80% of the cohort, with a mean age of 39.6 years (Tables 1 and 2). The mean body mass index (BMI) was 32.1 ± 6.5 (range: 19–53). Comorbidities were present in 43% of patients, including diabetes, hypertension, dyslipidemia, asthma, and ischemic heart disease.

Table 1.

Nationality Distribution

Nationality	Count	Percent
UAE	50	38.5
Oman	29	22.3
Sudan	8	6.2
Yemen	7	5.4
Egypt	4	3.1
Morocco	5	3.8
Dominican	3	2.3
Syria	3	2.3
Egypt	3	2.3
Philippines	3	2.3
Pakistan	3	2.3
Comoran	3	2.3
Iraq	2	1.5
Indonesia	1	0.8
Pakistan	1	0.8
Afghanistan	1	0.8
Lebanon	1	0.8
Nepal	1	0.8
Palestine	1	0.8
Syria	1	0.8

Table 2.

Age, BMI and RS Presence

Sample size (N)	130
Age, mean ± SD (years)	39.6 ± 12.2
BMI, mean ± SD (kg/m²)	32.1 ± 6.5
Sex, n (%)—Female	104 (80.0%)
Sex, n (%)—Male	26 (20.0%)
RS present, n (%)	111 (85.4%)
RS absence, n (%)	19 (14.6%)

RS was identified in 111 of 130 cases (85.4%), while absence of the sulcus was observed in 19 patients (14.6%; 95% CI: 9.56–21.70). Across the five RS morphological types, neither CV dissection time nor total operative time showed statistically significant variation (H = 8.20, P = .084; H = 7.66, P = .105) (Fig. 1; Table 3). However, when analyzed by RS presence versus absence, CV dissection time was significantly longer in cases without a visible RS (median 20 versus 18 minutes; U = 726.5, P = .030; effect size r = 0.31). Total operative time showed a nonsignificant trend toward prolongation in the RS-absent group (45 versus 38 minutes; U = 793.5, P = .086; r = 0.25).

FIG. 1.

Rouviere’s sulcus type distribution.

Table 3.

RS Type Comparison with CT Dissection Time and Overall Operative Time

RS type	CV dissection time (mean ± SD)	Operative time (mean ± SD)	n
Open	18.66 ± 9.03 minutes	40.88 ± 13.57 minutes	59
Slit	18.71 ± 8.14 minutes	43.95 ± 16.03 minutes	42
Scar	18.56 ± 9.72 minutes	39.56 ± 15.82 minutes	9
Absent	22.84 ± 7.77 minutes	47.42 ± 14.15 minutes	19
Close	40.0 minutes	90.0 minutes	1

Bold values are given to emphasize the effect of RS absence on increased CV dissection time and the overall prolongation of operative time.

Demographic variables, including age, sex, BMI, and nationality, showed no association with RS type or RS presence (all P > .20). Minor, controllable intraoperative bleeding occurred in 6 patients (4.6%), with no significant difference based on RS presence (Fisher’s P = .770). These bleeding events were associated with acute inflammatory pathology such as acute cholecystitis, empyema, and gangrene. The anatomical variation known as Moynihan’s hump, observed in 3.8% of the cohort, resulted in a slight prolongation of CV dissection time (exceeding 3 minutes) without affecting the total operative duration (Tables 4 and 5). A strong positive correlation was identified between CV dissection time and total operative time (ρ = 0.834, P ≈ 8.1 × 10⁻³⁵). Comorbidities did not significantly influence CV dissection time, total operative time, or LOS.

Table 4.

Complications Association–Multivariate Logistic Regression Predictors

Predictor	Direction	Significance
Age	↑ with complications	Not reliable (model separation)
BMI	↑ with complications	Not reliable
Acute cholecystitis	Strong positive	Not reliable
RS type	No effect	Not significant

Table 5.

Complications Cohort Comparison

Cohort	N cases	Complication rate (%)	Mean Calot time (min)	Mean operative time (min)	Median LOS* (days)	Most frequent complications
Acute-related (including empyema/gangrene)	27	22% (6/27)	27.4	58.2	2.0	Intraoperative bleeding (liver bed 5/port site 1)
Moynihan’s hump	5	0.0	22.0	40.4	1.0	—

* LOS = length of hospital stay.

Discussion

RS is a consistent anatomical landmark situated to the right of the hepatic hilum and anterior to the caudate lobe.^1–2 Its clinical significance in LC arises from its reliable spatial relationship to major biliary structures, which helps orient surgeons even when conventional anatomic planes are obscured.³ As an extra-biliary landmark, RS typically remains identifiable despite inflammatory distortion of the GB, cystic duct (CD), or surrounding tissues, except in rare cases of extensive extra-GB inflammation.^2–4

RS demarcates a “safe zone” for initiating dissection of CT, where the CBD consistently lies inferior to the sulcus, and the CD and CA course superior to it.^5–6 Beginning dissection at the level of RS may therefore facilitate timely and confident acquisition of the CVS. When CT is “frozen” by inflammation, the usual anatomical cues may be distorted, increasing the risk of misidentification and biliary injury.^7–8 In these settings, recognizing RS may support safer dissection along the correct plane adjacent to the GB neck while maintaining an appropriate distance from the CBD.

Despite these advantages, the reliability and universal applicability of RS remain debated in the literature, as highlighted in Table 6. Reported absence rates reach up to 30%, and RS morphology varies widely, including open, closed, slit, and scar types, each of which may influence visibility.^9–11 Moreover, depending solely on RS in complex cholecystectomy may create false reassurance if the sulcus is misinterpreted or obscured. Consequently, expert recommendations emphasize using RS together with other safety strategies such as CVS, bailout techniques (for example, fundus-first dissection), and intraoperative imaging modalities, including indocyanine green fluorescence cholangiography.^12,13

Table 6.

Comparison of Literature On Reliance On RS Anatomy and Related Critiques, Based On Synthesised Findings Rather than Direct Replication of Published Material

Number	Reference	Simplified key point/limitation
1	Cirocchi R, et al.¹⁴	“Poor visualization” and “improper performance” are common causes of injury; RS-related visibility issues may contribute.
2	Jha AK, et al.¹⁵	RS visible in ∼63.6%; not visible in ∼36%. Visibility and RS level vary, making it unreliable in many cases.
3	Kumar A, et al.¹⁶	RS visible in ∼90%, absent in ∼10%. RS-absent group had longer surgeries and more complications, including one Bile Duct Injury.
4	Ismaeil DA, et al.¹⁷	RS not seen in ∼23%. Thick gallbladder wall, adhesions, and inflammation reduce visibility and increase operative time.
5	Alius C, et al.¹⁸	RS can be misleading in distorted anatomy; recommends using multiple landmarks.
6	Mishra BB, et al.¹⁹	RS present in ∼92%, absent in ∼8%. Some RS types and pulsating vessels are unreliable; morphology affects usefulness.

In our cohort, RS was absent at approximately 15%, consistent with published lower-range estimates. When RS was absent, critical-view (CV) dissection time increased significantly with a moderate effect size (r ≈ 0.31), whereas total operative time showed only a nonsignificant upward trend (r ≈ 0.25). These findings indicate that RS presence contributes most directly during the dissection phase rather than influencing the overall operative duration. Notably, demographic variables, including age, sex, BMI, and nationality, did not correlate with RS type or visibility, suggesting that RS variation is intrinsic rather than patient dependent.

The overall incidence of minor bleeding complications was low (4.6%) and showed no meaningful difference between patients with or without RS. Most reported events were linked to acute inflammatory conditions such as empyema or gangrene rather than to RS-related structural variations, consistent with the observations of the Ismael Da et al. study.¹⁷ These factors led to only a slight increase in the total operative time without influencing the duration of CV dissection. The strong association between CT dissection time and total operative time (ρ = 0.834) highlights the pivotal impact of the dissection stage on operative efficiency. Moynihan’s hump, present in 3.8% of cases, prolonged CV dissection time by just over 3 minutes but did not alter the overall surgical duration.

This study has some limitations. Since it is a single-center observational study, the findings may not apply to wider populations or different surgical settings. The RS morphology groups were also uneven, with the closed RS subtype having only one case, making subgroup comparisons unreliable. Therefore, stronger conclusions come from comparing RS-present and RS-absent groups rather than focusing on specific RS subtypes.

Conclusions

In this 2-year observational study, RS was identifiable in most patients (85.4%). Its absence (14.6%) was associated with a significant increase in CT dissection time, while operative time showed only modest, nonsignificant prolongation. RS morphology did not influence operative metrics, and visibility was unaffected by age, sex, BMI, or comorbidities. Complication rates were low and comparable between groups, while CT dissection time remained the principal driver of overall operative duration.

These findings confirm that although RS can facilitate initial orientation during LC, it should serve as a supplementary landmark rather than a standalone safety guide, given its anatomical variability and limited impact on outcomes when modern safety strategies are applied. Ensuring the CVS, supported by bailout techniques and adjunct fluorescence imaging, when necessary, remains essential for safe dissection regardless of RS presence. Multicenter studies are recommended to further clarify the clinical utility of RS morphology in diverse surgical settings.

Footnotes

Authors’ Contributions

S.S.B., A.O.M., and F.H.A.M. conceived and designed the study, conducted data collection and analysis, and drafted the initial version of the article. S.S.B., Y.A.F., M.O., and U.B. contributed to data acquisition and assisted with data analysis. Q.A.A.D., S.J., A.E., U.B., and C.G. participated in data analysis and interpretation. P.S., C.G., A.H., A.E., and S.J. provided critical supervision, oversight, and expert guidance throughout the study. S.S.B., P.S., M.O., and Q.A.A.D. contributed to study design and offered essential supervisory input and methodological support. All authors critically reviewed the article, revised it for important intellectual content, and approved the final submitted version.

Ethical Considerations

This observational study was approved by the Ministry of Health and Prevention Research and Ethics Committee (REC), Ras Al Khaimah Subcommittee, United Arab Emirates, under approval number MOHAP/REC/2026/03-2026-F-M. Because the study involved no direct interaction with patients and did not collect any identifiable personal information, the REC granted a waiver of individual informed consent. The Declaration of Helsinki did not apply, as the study did not include human or animal participants and posed no potential risk to any individual.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for research and publication of this article.

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