Cawich SO, Kluger MD, Deshpande RR, Pearce NW, Alseidi A, Dapri G, Primrose JN, Gardner MT, Kedambady RS, Johnson S, Hewitt DB, Javed AA. Rouvière’s sulcus variants from a clinical perspective: A systematic review. World J Meta-Anal 2026; 14(3): 123961 [DOI: 10.13105/wjma.123961]
Corresponding Author of This Article
Shamir O Cawich, Department of Surgery, Meharry School of Medicine, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, United States. socawich@hotmail.com
Research Domain of This Article
Surgery
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Cawich SO designed the study; Cawich SO, Kluger MD, Pearce NW, Alseidi A, Johnson S, Gardner MT performed the research; Pearce NW, Primrose JN, Deshpande RR and Dapri G analyzed the data; Cawich SO, Kluger MD, Pearce NW, Gardner MT wrote the paper; Cawich SO, Kluger MD, Hewitt DB, Pearce NW, Gardner MT, Alseidi A, Kedambady RS, Johnson S, Primrose JN, Deshpande RR, Javed AA, Johnson S and Dapri G revised the manuscript for final submission.
AI contribution statement: Artificial Intelligence was not used in any way in the preparation or writing of this manuscript.
Institutional review board statement: This research has been approved by the institutional ethics committee.
Informed consent statement: This study only requires data collection and analysis, and does not include any patient identification information. Therefore, there is no need for a patient consent form.
Conflict-of-interest statement: The authors declare that there are no financial relationships, personal relationships or other scenarios that may represent potential conflicts of interest.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement- checklist of items.
Data sharing statement: Not applicable.
Corresponding author: Shamir O Cawich, Department of Surgery, Meharry School of Medicine, 1005 Dr. D.B. Todd Jr. Blvd, Nashville, TN 37208, United States. socawich@hotmail.com
Received: June 2, 2026 Revised: June 27, 2026 Accepted: July 29, 2026 Published online: September 18, 2026 Processing time: 101 Days and 15.3 Hours
Abstract
BACKGROUND
Rouvière’s sulcus is an important anatomic structure that may protect against bile duct injuries and guide parenchymal transection during hepatectomies. However, there are still multifarious classifications in use that prevent proper analysis of existing data.
AIM
To identify all existing data using a uniform classification of Rouvière’s sulcus.
METHODS
This study had two parts. First, a 5-year observational study of all consecutive cholecystectomies in an Eastern Caribbean nation was performed. Data were categorized using a standardized classification identifying open, closed, slit and scar-type variants. The second part of the study was a systematic literature review of medical archiving platforms, searching Rouvière’s sulcus variants. In instances where other classifications were used, we studied the descriptions and published images in order to categorize data using the standardized classification. The raw data were used to calculate global prevalence for each variant, which was then compared to that in our population using χ2 tests to compare contingency tables in SPSS version 20 (IBM Corp, Armonk, NY, United States). Fisher exact tests were used for values < 5. A P value < 0.05 was considered significant.
RESULTS
Data were collected from 356 persons in the observational study, revealing that Rouvière’s sulcus was present in 296 (83.2%) individuals. We encountered 140 open-type, 69 closed-types, 65 slit-types and 22 scar-type variants. There were 57 relevant articles from the systematic review that reported 76.88% global prevalence of Rouvière’s sulcus in 25196 persons. This was significantly lower than the prevalence of Rouvière’s sulcus in our population (83.2%; P = 0.005306). The Eastern Caribbean population was unique for having significantly lower proportions of open-type variants (39.33% vs 56.69%; P < 0001), and greater proportions of slit-type variants (18.26% vs 14.15%; P = 0.033397). The global prevalence of the closed-type Rouvière’s sulcus (23.64% vs 19.38%; P = 0.061988) and the scar-type Rouvière’s sulcus (8.11% vs 6.18%; P = 0.188331) were similar to that in Eastern Caribbean.
CONCLUSION
Although persons of Eastern Caribbean descent have a greater prevalence of Rouvière’s sulcus than global statistics, there are important differences in the proportion of variants. Surgeons practicing in these regions must be aware of these differences, particularly the lower prevalence of the “classic” open-type sulcus, as the other variants are more difficult to recognize intra-operatively.
Core Tip: Even in the year 2026, there is no consensus on a definition nor classification system for Rouvière’s sulcus, despite it being an important surgical landmark. In this systematic review, we used a standardized definition and classification system to extract raw data from 57 articles encompassing 25196 persons and used this to calculate the global prevalence of each variant of Rouvière’s sulcus. These data were compared to the data from a 5-year observational study in our local population. Statistical analyses revealed that the prevalence of Rouvière’s sulcus was significantly greater in the Caribbean population than global prevalence (83.2% vs 76.88%; P = 0.005306). Other unique differences were significantly lower proportions of open-type variants (39.33% vs 56.69%; P < 0001), and greater proportions of slit-type variants (18.26% vs 14.15%; P = 0.033397). These are important differences in the proportion of variants that are of great importance to surgeons practicing in these regions.
Citation: Cawich SO, Kluger MD, Deshpande RR, Pearce NW, Alseidi A, Dapri G, Primrose JN, Gardner MT, Kedambady RS, Johnson S, Hewitt DB, Javed AA. Rouvière’s sulcus variants from a clinical perspective: A systematic review. World J Meta-Anal 2026; 14(3): 123961
In the year 1924, Rouvière[1] described “grooves or furrows of the caudate lobe that spanned over one-third of the total width of the right lobe of liver”. They were ascribed many names, including sillon du processus caudé[1], incisura hepatica dextra[2], incisura of Gans[3] and Rouvière-Gans incisura[4]. Only after Couinaud[5] referred to it as the “sillon du processus caude de Rouvière” in 1957, did it become widely known by the eponymous name, Rouvière’s sulcus.
In the era of open surgery, Rouvière’s sulcus had little clinical significance and was largely ignored. There was a paucity of information about its frequency, morphology and variations in anatomical literature. That changed in 1985, when Eric Muhe performed the first laparoscopic cholecystectomy[6]. The benefits of laparoscopic surgery were rapidly recognized and the approach was quickly accepted as superior to open cholecystectomy[6]. However, the rapid shift to a laparoscopic approach led to a rise in bile duct injuries[7].
In order to reduce bile duct injuries, experts recommended performing operative cholangiography[8], attaining Strasberg’s critical view[9] and routinely identifying Rouvière’s sulcus[10,11]. Routine identification of Rouvière’s sulcus was recommended because it is visible laparoscopically[12] and anatomically related to the bile ducts[13]. Only after its clinical value was appreciated did we see a sharp rise in the number of publications on Rouvière’s sulcus, but multiple definitions of Rouvière’s sulcus also emerged.
While there seems to have been consensus to use the eponymous name, Rouvière’s sulcus, after Couinaud’s landmark publication in 1957[5], there is still no consensus on its definition. We performed a systematic literature search of all publications discussing Rouvière’s sulcus since its original description in 1924[1] up to March 30, 2025. Two investigators searched medical archiving platforms including, PubMed, MEDLINE, EMBASE, Google Scholar and research gate using the following keywords: Rouvière, incisura of Gans, incisura hepatica dextra, sulcus, furrow, fissure and groove.
We identified 57 publications that discussed Rouvière’s sulcus[1-5,12-63], and each author’s definition and classification were recorded in the Supplementary Table 1. This demonstrated that there was no consensus on the definition. Some authors defined Rouvière’s sulcus based on dimensions of the sulci[15,20,32], others based on its course[15,22,38], and others on visibility of the right hepatic pedicle[15] (Supplementary Table 1).
Further review of the publications, summarized in the Supplementary Table 1, also revealed that there was no consensus on a classification system. The Supplementary Table 1 lists the various classification systems encountered, many using similar terms, but ascribing different meanings to these terms. To give only one example, consider the term “open”. Some researchers define an open Rouvière’s sulcus as one that is continuous with the transverse hepatic fissure[2,20,42,50]. Others define an open sulcus as one that allows the right hepatic pedicle to be visualized at its base[13,15,21]. Others define an open sulcus as one that is uniformly wide for its entire length[13,15]. Yet others define open as one that is “open toward the gallbladder”[37] or “open toward the right hepatic pedicle”[32]. The Supplementary Table 1 lists similar multifarious definitions offered for the terms “fused”, “partially fused”, “sulcus”, “slit” and “scar”.
The existence of multifarious definitions and classifications do not allow us to scientifically interpret data. Therefore, we carried out a systematic review to identify all existing data using a uniform definition and classification for Rouvière’s sulcus.
MATERIALS AND METHODS
We secured IRB approval to carry out an observational study of all consecutive elective laparoscopic cholecystectomies performed in an Eastern Caribbean nation over a 5-year period from January 1, 2017 to December 30, 2021. The operating surgeons deliberately attempted to identify Rouvière’s sulcus as the first operative step, and this was corroborated by an independent observer. Once identified, the dimensions of the sulci were estimated using instruments in the operative field.
For this study, we used the standardized definition of Rouvière’s sulcus proposed by Cawich et al[42]: An impression on the visceral surface of the right hemi-liver intimately related to the right portal triad and running for various distances and/or directions into the right hemi-liver. The authors agreed to use this definition because it included known variants and it did not exclude sulci based on their dimensions, directions, length, width or visualization of portal structures. We utilized the classification[42] outlined in Table 1, that included all known variants of Rouvière’s sulcus: Open-type (Figure 1), closed-type (Figure 2), slit-type (Figure 3) and scar-type (Figure 4).
Figure 2 An intra-operative image during single incision laparoscopic cholecystectomy that demonstrates an open-type Rouvière’s sulcus (arrows), whose medial end is continuous with the transverse fissure, posterior to the gallbladder.
GB: Gallbladder; TF: Transverse fissure.
Figure 3 Intra-operative image during cholecystectomy, demonstrating a closed-type Rouvière’s sulcus, maintaining its posterior relationship to the gallbladder neck.
The medial end of Rouvière’s sulcus is separated from the transverse fissure by a bridge of liver parenchyma (L) so that the sulcus is not continuous with the transverse fissure. GB: Gallbladder; TF: Transverse fissure.
Figure 4 Intra-operative image taken during laparoscopic cholecystectomy, demonstrating a slit-type Rouvière’s sulcus (arrow), posterior to the gallbladder.
The sulcus is narrower than the operative instruments which are 5mm in diameter. GB: Gallbladder.
For the second part of this study, we conducted a systematic literature review using medical archiving platforms, including PubMed, MEDLINE, Google Scholar and the Cochrane database of Systematic Reviews. The following search terms were utilized: “Rouvière”, “incisura of Gans”, “incisura hepatica dextra”, “sulcus”, “furrow”, “fissure” and “groove”. All relevant studies were retrieved and the data and images reviewed in detail. We excluded data from duplicated publications, individual case reports, small series with < 10 cases, and publications that could not be accessed for independent review (Figure 1). In instances where other classifications were used, we studied the descriptions and published images of the variants in order to categorize them according to the standardized classification[42]. We reviewed all available published studies and extracted raw data, where available, to classify variants. The raw data were recorded in a Microsoft Excel® table and descriptive analyses were performed using SPSS version 20 statistical software.
The raw data extracted from published studies, tabulated in Table 2, were used to calculate global prevalence for each variant. Global prevalence was defined as the total number of individuals with a variant divided by the sum of the total number of individuals in each study. The global prevalence was then compared with the prevalence of each variant in our population using χ2 tests to compare contingency tables in SPSS version 20 (IBM Corp, Armonk, NY, United States). Fisher exact tests were used for values < 5. A P value < 0.05 was considered significant.
Table 2 Publications documenting the prevalence and types of Rouvière’s sulcus.
During the study period, we recorded data from 356 persons, noting that Rouvière’s sulcus was present in 296 (83.2%) individuals. The variants encountered included 140 open-types (Figure 2), 69 closed-types (Figure 3), 65 slit-types (Figure 4), and 22 scar-types (Figure 5). The raw data are presented in Table 2.
Figure 5 Intra-operative image taken at laparoscopic cholecystectomy, demonstrating a scar-type Rouvière’s sulcus (arrow).
There is only a vague impression/white line seen at the expected location of Rouvière’s sulcus, maintaining its posterior relationship to the gallbladder. GB: Gallbladder.
We retrieved 57 articles[1-5,12-63] that reported the prevalence and variations of Rouvière’s sulcus in a total of 25196 persons (Table 2). Although some authors utilized different classifications, detailed review of the published descriptions and images within the published articles allowed us to extrapolate data for comparisons. When the variant was not reported or could not be reliably extrapolated from published descriptions, data and/or images, the study data were excluded from the global prevalence statistics.
All 57 publications reported on the prevalence of Rouvière’s sulcus. We noted that the prevalence of Rouvière’s sulcus in our population was significantly greater (83.2% vs 76.88%) than the global prevalence.
The open-type sulcus was not defined and/or reported by the authors of 10 publications, and the data from these studies were excluded from calculation of global prevalence. In the remaining 47 publications an open-type Rouvière’s sulcus was present in 56.69% of unselected persons, significantly greater than its prevalence in the Eastern Caribbean (39.33%).
Eleven publications did not define or report a closed-type sulcus, and data from these studies were excluded. A further 2 were excluded because raw data could not be extracted to classify variants. In one publication[46], the data were excluded because the author groups scar-types and closed-types together. And in another paper[59] the data were excluded because the author grouped closed and slit-types together. In the remaining 46 publications, the closed-type sulcus was present in 23.64% of unselected persons, similar to its prevalence in Eastern Caribbean (19.38%). For Slit-type variants, two articles were excluded because the classification used was unclear. It appeared the authors grouped absent, slit and scar types together in one publication[47] and in the other closed and slit types were grouped together[59]. In a further 30 publications, the slit type was not reported or defined, and so data from these publications were also excluded. From the remaining publications, the global prevalence of a slit-type sulcus (14.15%) was significantly lower than that in our population (18.26%).
For the scar-type, 2 publications were excluded because one grouped scar and closed-types together[46] and another reported absent, slit and scar-types as a single group[47]. A further 23 publications did not define or report scar type sulci. The final calculated global prevalence for scar-type sulci (8.11%) was similar to that in the Eastern Caribbean (6.18%).
Three publications that described variants that did not fit into the classification systems used[18,20,54]. Ibrarullah et al[54] referred to a “double sulcus” which they defined as two parallel sulci. After studying the authors’ descriptions and the accompanying images, we were unable to determine whether they were referring to a closed sulcus (which was not included in their classification), an undefined variant or a totally separate sulcus. Therefore, these were omitted from further analysis. Kim et al[18] reported that 8% of persons who had “undefined” sulci, but they did not venture a definition or explanation and included no images to evaluate. It was unclear to our authors whether their “undefined” category referred to sulci that could not be seen due to adhesions or represented a variant that was not clearly described. The data from this study were also excluded from further analysis. In the final publication, Singh et al[20] referred to an “undefined” sulcus in 5.7% of persons, but it was not clear whether this meant a variant that could not be classified or a sulcus that could not be seen properly. Therefore, the data from this study were also excluded. After removing these three publications for vague data, we could find no reliable data to warrant an adjustment of the classification system used in this paper. There were also no “unclassified” variants encountered in our data set.
DISCUSSION
Unfortunately, multifarious definitions and classifications of Rouvière’s sulcus still appear in medical literature up to the year 2026, making interpretation of the literature difficult. Therefore, we suggest adopting the standardized definition and classification system used in Table 1. We acknowledge that each system has its individual merits and drawbacks, but the current definition/classification allowed inclusion of all known variants, regardless of their dimensions, directions, length, width or contents. It is also clinically relevant because it assists surgeons to recognize all Rouvière’s sulcus variants, permitting this landmark to be used more frequently for safe cholecystectomy[12] and liver resections[42].
Most authors consider the open-type sulcus as the “classic” Rouvière’s sulcus, and it is also the easiest to identify intra-operatively. Unfortunately, there was a significantly lower proportion of open-type sulci in this Eastern Caribbean population. This is important data to acknowledge, because a significant proportion of sulci will not be recognized at the time of operation if regional surgeons are only trained to recognize the “classic” open-type sulci. There were no differences in the closed-type and scar-type sulci. But we noted a significantly greater proportion of slit-type sulci in our population. Again, this places patients from the Caribbean diaspora at a disadvantage as these types of sulci are not as easy to recognize as the “classic” open-type sulci.
This means that surgeons practicing in this setting should be aware that they may need to be vigilant when performing right posterior sectionectomies and laparoscopic cholecystectomies because there are lower proportions of the “classic” open type and greater proportion of the slit-type sulci. The importance becomes apparent when we acknowledge that this study was performed in a resource-poor healthcare system, where there is inconsistent access to operative tools, such as operative cholangiography and indocyanine green. We suggest that surgeons operating in these environments make a deliberate attempt to identify variants by first identifying the transverse fissure of the liver and then examining along an imaginary parallel plane that extends from the transverse fissure into the right hemi-liver. Once there is a discernable anatomic structure present, the descriptors outlined in Table 1 can be used to distinguish between the closed, scar and slit-type variants.
It was previously been reported that this Eastern Caribbean nation is comprised of equal proportions of persons from the West African (40%) and North Indian (40%) diaspora as a result of the trans-Atlantic slave trade and indentured labour systems[64]. Therefore, we sought to compare the prevalence of variants to studies from these geographic locations. There were 12 publications that reported on Rouvière’s sulcus in North Indian populations[19,20,26,29,31,32,35,38,41,53,54,58]. When the raw data for each variant of Rouvière’s from North Indian populations were collated and compared to Eastern Caribbean data there were few similarities (Table 3). The only similarity between the North Indian and Eastern Caribbean populations was in the prevalence of the scar-type Rouvière’s sulcus (7.2% vs 6.18), and these were also similar to the global prevalence of scar-type Rouvière’s sulcus (8.11%). We acknowledge that these are preliminary comparisons due to the historical scarcity of granular morphologic data from these regions, but this also highlight the need for broader adoption of data acquisition using the standardized classification.
Table 3 A comparison of Rouvière’s sulcus variants in north Indian and eastern Caribbean diaspora.
There were no publications that studied Rouvière’s sulcus variants from West African nations. Therefore, we expanded our criteria to any publication that examined populations from the African diaspora. There were only two publications that examined Rouvière’s sulcus variants from South Africa[24] and from Kenya[40]. Their data are collated in Table 4. Again, the populations had few similarities, with only slit-type and scar-type Rouvière’s sulci having similar prevalence rates. This comparison, however, was limited by the small number of data available for comparison. Again, these are only preliminary comparisons due to the historical scarcity of granular morphologic data from these regions. It is important that we renew the call for broader adoption of data acquisition using the standardized classification.
Table 4 A comparison of Rouvière’s sulcus variants in the African and Eastern Caribbean diaspora.
There were limitations to this study. Firstly, the multifarious definitions and classifications encountered demanded that we retrospectively examine the raw data and images in published studies, and subsequently re-categorize the variants using a standardized classification system. However, this may have created the potential for misclassification because the current authors are assigning categories based only on the available information, which may have been limited, inconsistent or ambiguous. We attempted to minimize this misclassification bias by having two independent researchers categorize data. In the event that two independent researchers disagreed on the assigned category for variants from a published study, it was resolved during a physical meeting between all authors where the ambiguous published data/images were reviewed and discussed in order to arrive at a consensus decision for data exclusion and/or appropriate classification.
Secondly, this study relied on secondary data that could introduce bias if they were inaccurately reported and/or miscoded at the source. Inaccurate or ambiguous reporting would directly affect the ability of the current researchers to properly categorize the secondary data.
Finally, there is also the potential for bias in data availability, where manuscripts selected for publication, and inclusion in our systematic review, vary heavily depending on the geographic origin of data, relevance of data to high-income healthcare systems, and manuscripts showing statistically significant morphologic differences. The paucity of publications/data from West Africa may be an example of this kind of publication bias. When compounded, these forms of publication and misclassification biases may have compromised the systematic review.
CONCLUSION
Although persons of Eastern Caribbean descent have a greater prevalence of Rouvière’s sulcus than seen in global statistics, there are important differences in the proportion of variants. Specifically, the Eastern Caribbean diaspora has a lower proportion of open-type variants and a greater proportion of slit-type variants. Considering that the “classic” open-type variant is the easiest to identify intra-operatively, surgeons practicing in persons of Eastern Caribbean descent must be vigilant in order to identify these variants.
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