A hepaticojejunostomy is the standard palliative biliary bypass technique. A side-to-side choledochoduodenostomy is generally avoided as tumor progression can result in recurrent obstruction and cholangitis. It is also associated with a higher rate of hepatolithiasis, cholangitis (10–15 %), and the rare “sump syndrome” where the distal bile duct serves as a reservoir for stones and debris [16]. A cholecystojejunostomy, although technically easier to perform, relies on cystic duct patency to divert bile flow. Endoscopic studies of the hepatocystic junction suggest that only 50 % of incoming patients will be candidates for a cholecystojejunostomy. In addition, the tumor may involve the hepatocystic junction as it progresses leading to recurrent jaundice. A study utilizing Surveillance, Epidemiology, and End Results Medicare claims data demonstrated that patients treated with a cholecystojejunostomy had a biliary intervention rate of 7.5 % compared to 2.9 % for those treated with a hepaticojejunostomy at 1 year [17]. Recent reports indicate that a laparoscopic cholecystojejunostomy can be performed safely with a low rate of recurrent biliary obstruction [18]. This discrepancy between open and laparoscopic results warrants further investigation, however, and hepaticojejunostomy must be considered the optimal current palliative surgical approach for unresectable pancreas cancer. Laparoscopic hepaticojejunostomy is being performed with favorable outcomes. It is associated with less pain, earlier return of bowel function and a shorter hospital stay when compared to the open approach [19]. These studies, however, were small and the procedure requires advance laparoscopic skills to master. Robotic biliary bypass has been reported in the management of locally advanced pancreas cancer. To date, there is insufficient evidence to demonstrate superiority of the technique to the laparoscopic approach.