This case demonstrates an open HD procedure being used to rescue the adverse sequelae of an impacted distal CBD stone in a low-resource setting. A CDD had traditionally been indicated for palliation in patients with CBD obstruction caused by malignancy or in elderly patients with impacted stones [5]. A recent prospective study demonstrated CDD as a highly effective treatment for choledocholithiasis (CBD stones) in the presence of a dilated CBD in all age groups with low morbidity and mortality, provided a wide anastomosis was accomplished [6]. It has been reported as a more effective treatment of CBD stones than T-tube drainage but is regarded as an obsolete therapeutic method due to fears of higher morbidity, reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis, and “sump” syndrome [7]. “Sump” syndrome is theorized to occur from bile stasis and reflux of duodenal contents into the terminal CBD with bacterial overgrowth, resulting in cholangitis or hepatic abscess. The side-to-side CDD is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including the “sump” syndrome [8]. Because of the resutured dehisced cystic duct stump and the inflammation and adhesions below, a higher approach (HD) was utilized (Fig. 1). It is essential to ensure that the CDD/HD is at least 2.5 cm long in order to avoid stenosis, recurrent cholangitis, and further stone formation [9]. Except for significant postoperative biliary leakage which was managed conservatively, the outcome was successful as the jaundice, pain, and rigours resolved. Biliary anastomoses do not seal easily as intestinal anastomoses, thus the indication for a sub-hepatic drain [10]. A HD for obstructive CBD stones has not been reported in the English literature. HD is becoming an alternative to the Roux-en-Y hepaticojejunostomy in reconstruction after excision of a choledochal cyst because of fewer complications such as adhesive bowel obstruction, anastomotic leakage, and peptic ulcer. Apart from higher postoperative reflux/gastritis, it has a shorter hospital stay and similar operative benefits and outcome [11]. The utilization of HD for type IV Mirizzi's syndrome has also recently been reported [12]. Approximately 12% of patients undergoing surgery for symptomatic gallbladder stones will also have stones in the CBD [1]. It is appropriate that most patients with CBD stones are treated at the time of cholecystectomy. Thus, it is important to perform intraoperative cholangiography during a cholecystectomy and explore the CBD to retrieve any stones. The lack of fluoroscopy (image intensifier), fibreoptic instruments (choledoscope), or radiologically guided wire baskets or balloons in our setting did not make this possible. The operative hazards in blindly exploring the CBD for retrieving an impacted distal stone using a Desjardin (stone-grasping) forceps or a Bake's dilator that can be passed down the CBD to allow division of the papilla and biliary sphincter in a transdudenal sphincteroplasty include damage to the biliary tree and the production of a false passage by overzealous instrumentation [13]. There is also the risk of damage to the hepatic artery or portal vein [1]. A post- ERCP and sphincterotomy for retrieval of the impacted stone, if available, would have been useful in this case, but if it failed, an open exploration is indicated [1]. Currently, the rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones [3, 14]. Generally, the laparoscopic approach has the advantage for the patient over ERCP and sphincterotomy by being able to deal with the gallbladder and CBD stone(s) simultaneously (i.e., laparoscopic cholecystectomy and intraoperative LCBDE). This is corroborated by the fact that the standard treatment for symptomatic gallstones is laparoscopic, and there are few exceptions to a trial of a laparoscopic approach. However, open bypass procedures such as a HD may be an alternative to the traditional CDD in the management of the retained, impacted distal CBD stone especially in the presence of sepsis and adhesions around the supraduodenal CBD and in a low-resource setting [15].