Bile duct injury (BDI) is a serious complication of cholecystectomy. The incidence of aberrant biliary anatomy is approximately 1–1.5%, with anomalies of the right duct being the most frequent [2]. There are many factors which place the right posterior sectoral duct (RPSD) at risk of being ignored during cholecystectomy. These are: A low insertion of RPSD into the common bile duct close to the cystic duct, RPSD running behind the cystic duct to join the common bile duct, the cystic duct joining the confluence of the sectoral or hepatic ducts.

A 54-year-old female underwent uneventful laparoscopic cholecystectomy for acute cholecystitis. She developed pain in the right hypochondrium 4 days after surgery. There was no history of vomiting, fever or jaundice. Sonography showed a fluid collection in the gallbladder fossa, confirmed by computed tomography (CECT) scan (Figure 1). A 14-F Pigtail catheter was inserted to drain the collection. There was persistent drainage of 150–200 ml of bile per day. Endoscopic retrograde cholangiography (ERCP) was performed 10 days after initial surgery. It showed mildly dilated CBD without any obvious leak. The diagnosis of an isolated Strasberg type C bile duct injury [3] was made by magnetic resonance cholangiography (MRC) (Figure 3). On careful review of ERCP images, the right posterior hepatic duct was not visualized (Figure 2). The diagnosis of isolated Strasberg type C bile duct injury was confirmed. After period of six weeks the drainage remained 150-200 ml/day. A Roux-en-Y hepaticojejunostomy to the right aberrant hepatic duct was performed. Postoperative period was uneventful, liver function tests were normal.

Bile duct injury (BDI) is a recognized complication of laparoscopic cholecystectomy. Anomalous drainage of the right posterior sectoral bile duct into the cystic duct or the common hepatic duct is seen in around 2–5% of patients [1] increasing the risk of injury. Different BDI classifications are described in literature. Strasberg's classification [2] includes all types of injury including a leak. Right posterior sectoral bile duct injuries according to Strasberg's classification can be types B or C injuries.

The operative injury to these ducts as a result of division or clipping can result in bile leak or recurrent episodes of cholangitis [4]. These patients usually present with abdominal pain or fever if biloma becomes infected. In some patients, injuries to these ducts may go unrecognized as the injured area tends to atrophy.

Diagnosis and management protocol can be elusive. Abdominal ultrasound or CT-scan may reveal perihepatic fluid collection. Preoperative cholangiography is essential in defining the anatomy for a successful reconstruction following major bile duct injuries. The advantage of magnetic resonance cholangiopancreatography (MRCP) imaging is to delineate all ducts, even those that are excluded from the biliary system. The ERCP may be diagnostic and therapeutic. But ERCP has a limited role only in injuries where the connection of the extrahepatic tree to the duodenum is still intact. Bile leak in the presence of an intact common bile duct should raise the suspicion of RPSD injury [5] [6].

Intervention depends on the time period between surgery and recognition of the type, extent and level of the injury. External biliary drainage allows control of the leak and may obviate the need for surgery in 50% of patients [7]. In cases of persistent drainage after 8 weeks, a hepaticojejunostomy should be constructed to a Roux-en-Y jejunal limb.

Right posterior sectoral duct (RPSD) opening located close to cystic duct is dangerous scenario. Due to its location, it has high potential to get injured. The leak may then be erroneously attributed to injury to minor biliary radicle in gall bladder fossa and delay the diagnosis. Hence, high index of suspicion to diagnose such injuries, as interpretation of ERCP images may be erroneous.

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