Publication:

The role of Rouvière’s sulcus and R4U line in safe laparoscopic cholecystectomy: a prospective observational study of 130 cases

Background Bile duct injury (BDI) remains a serious complication of laparoscopic cholecystectomy (LC), most commonly due to misinterpretation of biliary anatomy. Rouvière’s sulcus (RVS) is an extra-biliary anatomical landmark that defines the plane of the common bile duct, while the R4U line delineates a safe zone for dissection. Identification of these landmarks may reduce the risk of BDI, particularly in difficult cholecystectomies.

Methods This prospective observational study was conducted at a tertiary care center between March 2023 and March 2025. A total of 130 patients undergoing elective LC for symptomatic gallstone disease was included. RVS was identified intraoperatively and classified according to presence, type, orientation, and dimensions. In cases where RVS was absent, dissection was guided by the R4U line. Operative difficulty was graded using the modified Nassar scale. Outcomes assessed included achievement of the critical view of safety (CVS), bile duct injury, bile leak, conversion to open surgery, and need for subtotal cholecystectomy.

Results Was identified in 106 patients (81.5%). The open type was the most common morphology (72.6%), with a predominantly horizontal orientation. CVS was achieved in all cases. No bile duct injuries were recorded. Bile leakage occurred only in patients undergoing subtotal cholecystectomy. Conversion to open surgery was required only in early cases of the study. With increasing adherence to RVS and R4U-guided dissection, difficult cases were successfully managed laparoscopically.

Conclusions Rouvière’s sulcus is a reliable and consistent anatomical landmark for safe laparoscopic cholecystectomy. When absent, the R4U line provides an effective alternative guide. Routine identification and use of these landmarks may significantly reduce the risk of bile duct injury.