Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-019-07131-z

Prevalence of anatomic landmarks for orientation during elective

laparoscopic cholecystectomies
Jennifer Schendel1 · Chad Ball1 · Elijah Dixon1 · Francis Sutherland1,2

Received: 5 May 2019 / Accepted: 17 September 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Background  We sought to determine the prevalence of common anatomic landmarks around the gallbladder that may be
useful in orienting surgeons during laparoscopic cholecystectomy.
Methods  The subhepatic anatomy of 128 patients undergoing elective cholecystectomy was recorded. We searched and
recorded the presence of five anatomic landmarks: the bile duct (B), the Sulcus of Rouviere (S), the left hepatic artery (A),
the umbilical fissure (F), and the duodenum (E). These are the previously described B-SAFE landmarks.
Results  We found that the duodenum and umbilical fissure were present reliably in almost all patients. The position of the
left hepatic artery could be reliably determined by its pulsation in 84% of patients. A portion of the bile duct could be seen
in 77% and the Sulcus of Rouviere was present in 80%. Furthermore, the hepatobiliary triangle was always found superior
or at the same level as the Sulcus of Rouviere.
Conclusions  We found that these five anatomic landmarks were reliably present. This suggest that using the B-SAFE land-
marks may allow a surgeon to more easily orient before and during laparoscopic cholecystectomy and prevent bile duct
injuries.

Keywords  Laparoscopic cholecystectomy · Bile duct injury · Anatomic landmarks · Orientation

Background
Since the advent of laparoscopic cholecystectomy in the
early nineties, the incidence of bile duct injuries (BDI) has
remained high. It is roughly three to four times the rate it
was in the open era (0.1% vs. 0.3–0.4%) [1–4]. This has
occurred despite an increasing understanding of this injury
and maneuvers that should prevent its occurrence. The “crit-
ical view of safety” was introduced in 1994 [5] and has been
widely adopted. Its basic tenant is that if a surgeon widely
and completely dissects the hepatobiliary triangle leaving
only two structures, the cystic duct and the cystic artery, it
becomes impossible to damage the main bile duct. However,
the bile duct damage continues.
* Francis Sutherland
francis.sutherland@albertahealthservices.ca
1
Department of Surgery, University of Calgary, Calgary,
Canada
2
Foothills Hospital, 1403 29th Street NW, Calgary,
AB T2N 2T9, Canada
Early on, Hugh et al. [6] put forward the concept that a
bile duct injury is a navigation error similar to that which
occurs with pilots. He introduced the idea that the funda-
mental problem is spatial disorientation of the surgeon/pilot
as a cause of these injuries. Hugh [7] also introduced the
concept of using the sulcus of Rouviere as a fixed landmark
for navigating during cholecystectomy.
Other anatomic landmarks are available for surgeon ori-
entation [8, 9]. The gallbladder is clearly an important early
landmark with the fundus being the key point of initial ori-
entation. Unfortunately, its’ inferior border is often obscured
by fat or inflammation and the lower gallbladder can overly
the bile duct itself. Several years ago, we introduced the
idea of using a set of landmarks around the gallbladder for
surgeon orientation [10]. These five B-SAFE landmarks
(mnemonic) are the Bile duct itself, the Sulcus of Rouviere,
the left hepatic Artery pulsation, the umbilical Fissure, and
the duodenum (Enteric) (Fig. 1).
We felt that it was important to know how often these
landmarks are actually present in elective cholecystectomy
patients. This observational study answers this question.

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Fig. 1  This photograph demonstrates the five B-SAFE landmarks in
the subhepatic space of a low BMI patient. The bile duct (B) is seen
in its entirety and the Sulcus of Rouviere (S) can be visualized below
the Hartman’s Pouch. The left hepatic artery (A) can be seen on the
left side of the porta hepatis (in real time its pulsation makes it clear).
An open Umbilical Fissure and the Duodenum (E, enteric) are readily
visible
Methods
We collected anatomic data prospectively on consecutive
patients undergoing elective laparoscopic cholecystecto-
mies between September 2015 and February 2017 at three
centers (Foothills Medical Center, South Health Campus
and High River hospital). We found one hundred twenty-
eight patients who matched the entry criteria. These
patients were operated by one surgeon (FS). Patients were
eligible for inclusion in this study if they had abdomi-
nal pain and stones or sludge confirmed on an ultrasound,
consistent with biliary disease. Patients were considered
ineligible if they had non-biliary stone disease, were less
than 18 years of age or were deemed non-operative can-
didates. Emergency patients were also excluded. Ethical
review and approval for this study was provided by the
health research ethics board of Alberta.
The presence of landmarks was recorded before any
dissection. To determine the presence of these landmarks
three maneuvers had to be performed after the gallbladder
was elevated. Liver segment 4 was lifted to identify the
upper bile duct, hepatic arteries, and umbilical fissure. The
duodenum was pushed down to see the lower bile duct, and
the gallbladder was retracted to the left to search for the
Sulcus of Rouviere.
Each of the B-SAFE landmarks was recorded as pre-
sent or absent. If any portion of the bile duct was visible
it was deemed present. Portions of bile duct visualized
were divided into “upper”, “middle” or “lower”. Upper
was defined as below the hilar plate, middle was near the
cystic duct junction, and lower was considered just above
the duodenum. The sulcus of Rouviere landmark was pre-
sent if a “triangle”, “hole”, or “notch” was seen in the
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Surgical Endoscopy
liver parenchyma on the right side of the gallbladder. The
hepatic artery was determined by the presence of a local-
ized pulsation on the left side of the porta hepatus. Only
the left hepatic artery was considered a landmark. The
right hepatic artery was deemed visible if a pulsation was
seen centrally or to the right of the bile duct. The umbilical
fissure landmark was deemed present if it was seen to be
completely “open” or its position could be determined by
at least a lower notch in the bridging liver tissue between
segments 4 and 3. If the fissure was covered with liver
tissue and no notch was visible it was deemed “absent”.
Operative problems were recorded prospectively and
patient outcomes were determined by a chart review.
Additionally, we analyzed the relationship of the Sul-
cus of Rouviere to the posterior hepatobiliary triangle
after gallbladder elevation. At the start of the dissection,
before releasing any of the posterior leaflet attachments, we
recorded whether the hepatobiliary triangle was below the
sulcus, at the same level as the sulcus, above the sulcus or
well above (greater than 2 cm).
Patient characteristics including patient body mass index
(BMI) were recorded (obese was defined as a BMI of 35 or
greater).
Descriptive statistics were used to describe this patient
cohort and the presence or absence of these characteristics.
Rates at which each of the B-SAFE landmarks were visu-
alized were calculated. For comparative analyses, Fisher’s
exact test was used and two-sided p-values of less than 0.05
will be considered significant. All data was analyzed using
IBM SPSS version 19 (IBM Corporation, USA).
Results
The results were collated from the data sheets. In several
instances data was missed including one data point on the
Sulcus of Rouviere, 5 data points on the left hepatic artery,
and 2 data points on the left hepatic artery. This accounts for
the variable denominators.
The prevalence of the five anatomic landmarks are
recorded in the Table 1. Any portion of the bile duct was
seen in 77% of patients. The entire bile duct was seen in 7%
of patients. It was most frequently seen just above the duo-
denum (67%) and least frequently in its mid portion (20%).
The Sulcus of Rouviere landmark was present in 80% of
patients with the most frequent form being a triangle (54%).
Careful scrutiny of the left side of the porta hepatus revealed
a left hepatic artery pulsation in 84% of patients. The right
hepatic artery was visible in only 16 of 122 patients (13%)
and its position was variable. An open umbilical fissure was
seen in 67% of patients, but even if it is covered by a bridge
of liver tissue a lower notch usually revealed its position. In
only 4 cases we could not determine its’ position at the top
Surgical Endoscopy

Table 1  Prevalence (%) of B-SAFE landmarks of rapidly advancing disease and died. There were no bile
Landmark No. seen/no. reported (%)
duct injuries but 2 “near misses” occurred, as defined by
dissection on the left side of the bile duct in the porta hepatis
Bile duct (any portion) 99/128 (77%) triangle. In both of these cases the gallbladder overlay the
Upper 56/128 (44%) common bile duct. Two patients had postoperative retained
Middle 25/128 (20%) common bile duct stones requiring ERCP extraction.
Lower 86/128 (67%)
Entire bile duct 9/128 (7%)
Absent 29/128 (23%)
Sulcus of Rouviere 101/127 (80%) Discussion
Triangle 67 (53%)
Hole 24 (19%) Bile duct injuries during a laparoscopic cholecystectomy are
Notch 10 (8%) an important complication leading to high morbidity and
Absent 26/127 (20%) mortality. It has been postulated that the error of perception
Hepatic artery (left) 103/123 (84%) and orientation is the cause, rather than surgeon knowledge
Umbilical fissure 124/128 (97%) or decision-making. Fixation of the initial anatomic inter-
Open 83/128 (65%) pretation without a careful survey or inappropriate orienta-
Covered with notch 41/128 (32%) tion at the start of the dissection can allow for a cascade of
Absent 4/128 (3%) mistakes that eventually results in bile duct damage [11–13].
Duodenum 122/126 (97%) There are several reasons that using a laparoscope may
predispose BDI. During open cholecystectomy the surgeon
has a broad view of the subhepatic space and has a natu-
of the porta hepatus. The duodenum also proved visible in ral view of orientation landmarks in this space. This prob-
all but 4 patients. ably occurs subconsciously. Magnification provided by the
All cases (128) had at least one B-SAFE landmark visual- laparoscope narrows this field and blocks out these natural
ized. Ninety-eight percent had at least 2, 91% at least 3, 65% orientation features [14]. In situations of difficulty there is
at least 4 and 56% percent had all five landmarks present. always a tendency to more narrowly focus one’s attention.
Twenty-seven obese patients were identified (21%). In The scope may be brought closer. The view is also from
this cohort, all had at least 1 B-SAFE landmark, 96% had below rather than direct and this may further limit orienta-
at least 2, 89% at least 3, 85% at least 4, and 52% had all 5 tion [14].
landmarks. When compared to non-obese patients the duo- There has been a very little discussion of the use of land-
denum was less often visualized (89% vs 99%; p = 0.04). marks in general surgery. It is intuitive that all surgeons use
There were no statistical differences when identifying the landmarks to orient themselves throughout all operations.
other 4 B-SAFE landmarks between obese and non-obese. Yet we rarely teach landmarking to our surgical residents. A
We analyzed the hepatobiliary triangle in relation to the good landmark has three salient features. It must be present
sulcus of Rouviere. We noted that in all cases where the in high percentage of cases. It must be easy to find and rec-
Sulcus was identified, the hepatobiliary triangle was never ognize. Lastly, it must convey accurate relational informa-
below the sulcus. The sulcus was at the same level in 11% tion about the critical structures in the dissection. One might
of cases, but in the majority (89%) the hepatobiliary triangle think that the gallbladder would be the prime landmark for
was seen either above or well above the sulcus. cholecystectomy. Indeed, the fundus of the gallbladder does
We found that in 7 of 128 (5.5%) cases the gallbladder/ provide a key to early orientation for dissection. Unfortu-
Hartman’s Pouch overlays the common bile duct prior to nately, the bottom of the gallbladder and Hartmann’s pouch
starting the dissection. In only 2 cases we were able to iden- can be very misleading when it comes to the position of the
tify a sectoral duct by observation. bile duct. The bottom of the gallbladder may be fused to the
Of the 128 consecutive patients two had to be converted duct because of inflammation or may quite simply override
to open, one because of epigastric port bleeding and one the entire porta hepatus. Hartmann’s pouch may be under,
because of extensive inflammation. These patients under- beside, or on top of the bile duct. In both “near miss” cases
went subtotal cholecystectomy. Two additional patients had the initial disorientation occurred when the gallbladder over-
laparoscopic subtotal cholecystectomies because of inflam- lay the common bile duct. Cystic ducts of variable lengths
mation around the cystic duct. There were 2 significant and direction add uncertainty to the relative positions of the
bleeds from the middle hepatic vein in the gallbladder plate gallbladder and extrahepatic bile duct. It is key to understand
treated with cautery. One patient had gallbladder cancer that during cholecystectomy our goal is to landmark the bile
diagnosed on pathology. She was not reoperated because duct and not the gallbladder.

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The five structures we have chosen to landmark the bile
duct meet the three tenants of good landmarks. Because the
bile duct is the critical structure in question, anytime we can
identify its’ path we improve safety. It was surprising how
often (77%) at least one part of the duct could be visualized
with a simple search strategy. The entire bile duct could be
seen in 7% of patients.
The Sulcus of Rouviere is an established landmark [7].
Our observations are similar to other studies [15] with three
basic forms, an open triangle being the most common (54%).
It was easy to find and reliable in its position. It has been
widely recognized that any dissection below the Sulcus
risks bile duct injury. Indeed, we found that in our series
of patients the true hepatobiliary triangle was never found
below the Sulcus. This helps us fix our superior/inferior
position. We also observed that in dissecting this triangle
the gallbladder moved superior and away from the bile duct
[16].
The left hepatic artery has not been previously proposed
as a landmark for the bile duct as it cannot be seen directly.
However, a few seconds of gaze can fix its position by
observing its pulsation on the left side of the porta hepatus.
This is crucial as it helps us fix our left/right position in the
subhepatic space. There is always some space between this
artery and the bile duct. It is this critical space, in the porta
hepatis, on the left side of the bile duct that a disoriented
surgeon dissects in a classic bile duct injury. Recognizing
the closeness of this pulsation from the left hepatic artery
should clue the surgeon that he or she is on the wrong side
of the bile duct and in the wrong dissection plane.
The umbilical fissure is easy to identify and almost
always present. It is also important for left/right orientation.
If a surgeon finds they are dissecting under the fissure it is a
red flag for spatial disorientation.
The duodenum is also easy to identify and commonly
seen. A surgeon who finds herself too close to the duodenum
is too low, and the dissection is near the common bile duct.
The use of these landmarks are not mutually exclusive. At
least one landmark was present in every patient. There are
two superior/inferior landmarks, two left/right landmarks,
and of course the bile duct structure itself. Even if some
are not present the others should allow surgeons to prop-
erly fix their dissection in space. Because these cases were
elective cholecystectomies, few patients had an active acute
inflammation. Patients with severe acute cholecystitis will
no doubt have fewer landmarks visible, but the ones that
are seen can be even more valuable. We also showed that in
obese patients, with the exception of the duodenum, these
landmarks are easily found.
The more landmarks we have the easier it is to navigate.
We have previously suggested that every surgeon uses a
stored cognitive map to navigate the operative field [17]. It
is crucial that the surgeons map be fixed correctly to prevent
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Surgical Endoscopy
misinterpreting the anatomy. Furthermore, anatomic clues
along the process of dissection may alert the surgeon that
he has strayed into the wrong plane. Any type of bile duct
injury usually occurs by being too far left and too inferior,
often in the “porta hepatus triangle” rather than the “hepa-
tobiliary triangle”. Dissection along the left side of the bile
duct is a “near miss”. Using the landmarks around the gall-
bladder to sense this may allow surgeons to reorient.
Changing the behavior of surgeons is a difficult task. The
implementation of the safe surgery checklist was certainly
resisted by many. However, these types of debiasing strate-
gies can be very helpful when it comes to reducing errors.
We have proposed a bile duct time-out where a surgeon stops
prior to dissecting the gallbladder, backs the camera out,
and checks orientation by identifying these five B-SAFE
landmarks. It takes seconds. We have started to routinely
teach this to our faculty and residents at our institution. Its
impact on the local incidence of bile duct injuries remains
to be seen.
There is no one solution to preventing bile duct injuries,
but by using additional strategies to the “critical view of
safety” we may begin to reduce incidence of these devastat-
ing injuries. Building strong safety habits is a career long
pursuit.
Compliance with ethical standards 
Disclosure  Dr. J Schendel has no conflicts of interest or financial ties
to disclose. Dr. C Ball has no conflicts of interest or financial ties to
disclose. Dr. E Dixon has no conflicts of interest or financial ties to
disclose, Dr. F Sutherland has no conflicts of interest or financial ties
to disclose.
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