bile duct injuries remain one of the most devastating complications of both open and laparoscopic cholecystectomy ( lc ) . heuristic errors of perception in which surgeons fix anatomical reference points incorrectly and commence dissection in an area of danger is perhaps the most common cause of bile duct injuries . injury prevention theories have suggested that strategies to prevent injuries would be most effective at the time of anatomical identification and orientation , and prior to dissection . we present three cases of right sectoral duct injuries , two of which had right posterior sectoral duct ( rpsd ) injuries noted on intraoperative cholangiogram ( ioc ) ( strasberg type c injuries ) ( figures 1 , 2 ) , while the third had a right sectoral duct injury noted on postoperative endoscopic retrograde cholangiopancreatography ( ercp ) ( strasberg type a injuries ) ( figure 3 ) ( table 1 ) . biliary injuries were primarily repaired and stented over 14 french ( fr . ) caliber t - tubes brought through separate choledochotomies in the first two cases , while an ercp was utilized for postoperative evaluation and therapy in the third . although most leaks originate from the cystic duct ( cd ) stump and common bile duct ( cbd ) , those from aberrant sectoral bile ducts are also common but rarely discussed . biliary tree anomalies are present in up to 25% of patients , with aberrant right hepatic ducts being the most common . aberrant sectoral duct arise most commonly from the right liver and drain into the common hepatic duct ( chd ) or cd ( figure 1(b ) ) . an aberrant right sectoral hepatic duct usually represents the only route of biliary drainage for the portion of the right hepatic lobe it drains . the most dangerous sectoral variant is when the cd runs along side of a low - lying aberrant right sectoral duct . most commonly this is the rpsd , which drains segments 6 and 7 and is present in 4.88.4% of the population [ 4 , 5 ] . injuries to these ducts are likely underreported since they may be asymptomatic and often unrecognized as the injured area atrophies over time . three patients underwent lc and sustained iatrogenic rpsd injuries requiring operative or endoscopic management .   in the first two cases , a review of iocs ( figures 1 , 2 ) demonstrated aberrant biliary anatomy and injuries to low - lying rpsds . a tangential injury to the rpsd in both cases was successfully recognized and repaired primarily by duct - to - duct anastomosis . t - tube ( 14 fr . ) stenting of the repair was performed through a separate choledochotomy , with the upper arm of the t - tube crossing the injured rpsd . post - repair cholangiogram obtained through the t - tube revealed opacification of all segments of the right liver without extravasation or stricture ( figure 2 ) . these injuries may have escaped detection and opacification at ercp due to the lack of communication of the injured ducts with main biliary channels , thereby rendering endoscopic management impossible . such injuries should be suspected when a bile leak persists despite  normal  cholangiography and there is a presumed failure of a  cd stump leak  to close after biliary stent placement . in the third case , an ercp ( figure 3 ) revealed the bile leak to arise from an injured aberrant right sectoral duct with anomalous communication to the left biliary system . pilots and astronauts need to make accurate judgments of motion to perform critical aerospace tasks safely and effectively to avoid disaster . although laparoscopic biliary surgery is over 15 years old , biliary injuries continue to be a major source of morbidity and concern for surgeons . despite continued efforts , the rate of injury has leveled off at 0.5% for lc . typically , biliary injuries occur either due to technical problems or anatomical misidentification of the cd , latter being the most common cause . two structures most often misidentified as the cd are the cbd or an aberrant right hepatic duct ( rhd ) . the resultant injuries are of two main types  cbd mistaken for cd is clipped and divided ; and the segment of an aberrant rhd ( between entry of the cd and junction of the chd ) is misidentified and either ligated , transected or injured during dissection in calot 's triangle . way et al .   analyzed 252 patients with laparoscopic bile duct injuries and concluded that these injuries stem principally from visual perceptual illusion , and not from errors of skill , knowledge , and judgment . this misperception theory is compelling in that even on identification of irregularities corrective feedback did not occur , thus supporting the notion that the native human mindset to hold firm to our assumptions is strong . in spite of excellent laparoscopic visualization , misidentification of extrahepatic accessory bile ducts during lc is a frequent cause of complications . ioc is good at avoiding misidentification of the cbd , but poor at detecting an aberrant rhd depending on the location of the cd puncture site . nevertheless , performing complete circumferential dissection of the gallbladder neck and cd before cholangiography or clip placement should enable visualization of any variant anatomy . this recommendation was not followed in two of our cases , hence non - circumferential dissection and early clipping was performed . a choledochotomy for the cholangiogram was mistakenly made into an aberrant rhd instead of the cd ( figure 1 ) . this type of injury has been described as a class iv  lawrence way  injury   due to misidentification of the rpsd as the cd resulting in a lateral injury , transection or ligation of an unseen low - lying rhd . when correctly interpreted , routine ioc increases the chances of recognizing bile duct injuries , but it may not lower their incidence . this prompts us to conclude that more than a routine ioc may be essential to prevent biliary injuries . magnetic resonance cholangiopancreatography ( mrcp ) is an excellent noninvasive imaging modality that is capable of demonstrating aberrant biliary anatomy . analyzed anatomical variations of the biliary tree with multislice - computed tomography ( mct ) cholangiography in 113 patients . mct cholangiography provided clear images of aberrant bile ducts in 18 patients  major type ( draining liver segment ) in 9 ( 8% ) and minor type ( draining liver subsegment ) in 9 ( 8% ) . alibrahim et al .   demonstrated the efficacy of spiral ct - iv cholangiography with 3d reconstructions for imaging the biliary tree . using this technique excellent visualization of the biliary anatomy was achieved with good opacification of at least first - order or third - order bile ducts in 91% or 84% of patients , respectively . despite their efficacy , routine ercp , mrcp , and contrast - enhanced mct cholangiography are expensive tools , and should be reserved for select cases .   irrespective of information derived on imaging , improvisation of surgical technique is necessary to avoid biliary injuries . careful dissection ,  conclusive identification  of anatomy with clearing of the hepatocystic triangle of all fat , and determination of  endpoint  in the dissection is pivotal in prevention of intraoperative complications . in 1995 strasberg et al .   introduced a technique for  conclusive identification  of the cystic structures at lc based on a other important strategies include the use of a 30-degree telescope which provides en face view of the calot 's triangle and its intermittent withdrawal gives the surgeon an overall perspective and spatial orientation . simulation - based surgical training and the availability of biologically - based models of human body architecture will permit virtual reality to serve as quantitative models of human self - motion perception . performance analysis in heading estimation and related motion perception tasks will aid in the design of training regimes for surgeons in the near future . robotic instruments to simulate the motions of the surgeon 's wrist and the use of 3d imaging to immerse the surgeon in a 3d video operating field may also offer potential solutions to the inherent problems of traditional laparoscopic surgery . though exciting , these technologies are still in an early stage of development , and each device entails its own set of challenges and limitations .   despite all the emerging advances bile duct injuries will still occur , and if they do conversion to open procedure is usually indicated . repair should be attempted by general surgeons only if the techniques of dissection and reconstruction are common and familiar , and every effort should be made to conserve bile duct length . repair techniques for minor injuries to the lateral wall of the chd or cbd are familiar to most general surgeons , but injuries to aberrant ducts and those at or above the confluence of hepatic ducts require operative skills more likely to be available at specialized hepatobiliary units . when such expertise is unavailable at the time of injury , closed suction drains should be placed in the region of hepatoduodenal ligament and referral made expeditiously .
although laparoscopic cholecystectomy ( lc ) has been widely accepted as the standard of care , it continues to have a higher complication rate than open cholecystectomy . 
 bile duct injury with lc has often been attributed to surgical inexperience , but it is also clear that aberrant bile ducts are present in a significant number of patients who sustain biliary injuries during these procedures . 
 we present three cases of right sectoral hepatic duct injuries which occurred during lc and provide a discussion of the conditions which are likely to lead to these injuries , as part of a strategy to prevent them .