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Perihilar cholangiocarcinoma is a rare, aggressive tumor whose only curative treatment is complete surgical resection followed by adjuvant chemotherapy. Surgery is technically complex, with a high risk of complications, notably postoperative liver failure. Preoperative biliary drainage plays a central role in preoperative optimization, but it should never be performed outside an expert center, without prior multidisciplinary consultation. It is not an emergency procedure in the absence of angiocholitis, and its indication must be guided by the forthcoming surgical strategy. The aim is to reduce bilirubinemia, prevent biliary infections, and prepare a future functional liver sufficient to avoid postoperative complications. The choice of technique (endoscopic or percutaneous) depends on anatomy, type of stenosis, and local expertise. An error in the drainage strategy (such as placing an uncovered metal prosthesis) can render the tumor unresectable and seriously compromise prognosis. The optimal approach is based on coordinated management, in a specialized center, from the diagnostic phase through to surgery.