Surgical management of 24 cases of primary carcinoma of the main extrahepatic bile duct are presented. This tumour forms less than 2% of the cases in which bile duct surgery is required and its intermittent appearance makes rational exploitation of surgical management difficult. Obstructive icterus is the main and constant symptom. Preoperative diagnosis of the obstruction necessarily requires transhepatic cholangiography following incision under local anaesthesia. Resection starting from the middle third of the duct was performed in 4 cases. A palliative biliodigestive shunt was applied in 5 and decompression by means of a Kehr tube was adopted in 11. Intraoperative mortality was high, mainly on account of frequent liver cell damage. In some instances, however, survival was measured in years, even in the absence of surgical resection. Surgery must thus be tailored to the patient's strength. When the patient's condition is good and the tumour is situated in the common bile duct or distal hepatic duct, an internal shunt can always be attempted. When higher segment of the duct are involved, a shunt on a Kehr tube or in the form of a U probably offers the best solution.