With advances in liver surgery, most large primary hepatocellular carcinoma (HCC) or hepatocellular carcinoma in the portal region can be resected in one stage or reduced by hepatic artery chemoembolization (TACE) to obtain a second stage resection under conditions where the reserve function of the liver is still tolerable. However, when hepatocellular carcinoma (HCC) invades the portal vein trunk or the first level branch to form portal vein tumor thrombi (PVTT), surgical resection is often considered inappropriate, and in the past, it was mostly treated negatively or abandoned, and most patients died within a few months. In recent years, we have taken active treatment measures for hepatocellular carcinoma combined with PVTT, i.e. resection of hepatocellular carcinoma together with PVTT or removal of cancer thrombus, and some patients were treated with hepatic artery (HAI) and/or portal vein cannulation (PVI) after resection, and achieved satisfactory results, as described below. (1) HCC resection: 28 cases of left outer lobe resection, 35 cases of left hemicolectomy, 4 cases of left trilobar resection, 8 cases of middle lobe resection, 20 cases of right hemicolectomy and 44 cases of right partial hepatectomy. (2) Hemihepatic flow blockade: In order to avoid ischemia-reperfusion injury of the whole liver caused by Pringle method, Makuuchi [1] reported in 1987 the use of hemihepatic flow blockade method, which selectively blocked the venous and arterial blood flow to the liver in the left or right hemihepatic, with the advantages of no ischemic concern in the healthy liver and clear resection boundary after blocking the hemihepatic, and the disadvantage of continuous bleeding in the plane of the unblocked hemihepatic when the liver is cut. Hemihepatic flow block is suitable for resection of liver tumor in liver tissue with poor underlying liver function, and further damage to liver function can be avoided by using this method. This method is more suitable for the condition of high number of cirrhotic patients in China. Yan Lunan [2] advocated the application of this method and made important improvements. We adopted a selective entry hepatic blood flow block with reference to this method, i.e., through the Glisson route, without dissecting the first hepatic hilar. The square lobe of the liver was exposed, 1 cm above the junction of the anterior layer of the hepatoduodenal ligament with the peritoneum, and the hepatic peritoneum of the square lobe of the liver was incised by electric knife, and the cut edge of the hepatic peritoneum near the transverse sulcus side of the liver was lifted and slightly separated immediately under the peritoneum. Under the guidance of the index finger, the right hepatic tract is introduced into the right hepatic tract blocking band by using a renal tractor at the junction of the portal vein bifurcation and caudate lobe; the renal tractor is introduced into the left hepatic tract blocking band by passing through the small omental capsule after the left hepatic tract; when cutting the liver, the blocking band is tightened to block the blood flow to the left and or right hepatic halves. This method is simple and easy to apply in clinical practice. (3) Control of hepatic vein: In the past, extrahepatic control of the right hepatic vein and the left middle common trunk was considered to be an operation full of danger. Especially the separation and control of the common trunk, because the average length of the common trunk is only 1 cm, and in a few cases the middle and left hepatic veins do not form a common trunk but merge into the vena cava separately. With the introduction of modified dorsal camelid liver transplantation, the anatomy of the extrahepatic hepatic veins is becoming better known to surgeons. Our experience is that for the right hepatic vein, the foveal lax tissue in front of the superior and inferior hepatic vena cava is carefully separated to reach the interhepatic vein notch, and the root of the right hepatic vein and the common trunk of the left and middle hepatic veins is bluntly separated to reveal the right hepatic vein. The inferior vena cava ligament was dissected at the right edge of the inferior and superior hepatic vena cava immediately adjacent to the liver to reveal the right hepatic vein converging into the right posterior edge of the inferior vena cava. A gentle blunt separation of up to 1 cm or more is made with the index finger between the hepatic veins in the posterior hepatic along the anterior inferior vena cava downward, and then carefully separated with vascular forceps along the anterior inferior vena cava toward the gap between the right hepatic vein and the angle of the inferior vena cava, which is pierced in the right anterior inferior vena cava, below the right hepatic vein, and an 8-gauge urinary catheter or silk is introduced. For the common trunk of the left middle hepatic vein, the dense portion of the hepatogastric ligament is separated between the superior border of the caudate lobe, the right border of the cardia and the cleft of the venous ligament to reach the left border of the inferior vena cava. The index finger is gently and bluntly detached along the posterior aspect of the left middle hepatic vein common trunk, and then the vascular clamp is used to continue the detachment. The index finger of the left hand is used as a guide to penetrate the left anterior margin of the inferior vena cava opposite to the tip of the clamp, and an 8-gauge urinary catheter or silk thread is introduced, or further detached with the vascular clamp, and the left and middle hepatic vein common trunk is closed and cut with the vascular closure, which is very convenient, fast and reliable. Successful placement of a hepatic vein trunk blocking band allows for safe performance of a regular hepatectomy [3]. We tried this method in our group of hepatectomy cases and successfully prepositioned the right hepatic vein and/or common trunk blocking band in 85 cases. 3 cases were unable to free the right hepatic vein due to huge tumor and the bulging portion obscuring the vena cava ligament, and only prepositioned bands in the upper and lower hepatic vena cava were used. These experiences suggest that extrahepatic control of the hepatic veins can be achieved in most cases through improved dissection techniques and careful handling. When using this method, one should be very familiar with the anatomy of the hepatic veins and should still initially use preplaced blocking strips in the inferior and inferior hepatic vena cava so that the inferior vena cava can be blocked for repair in case of injury to the main hepatic vein. (4) PVTT treatment method: For HCC in the left lobe of the liver with left branch of portal vein, the right branch of portal vein should be isolated first, and the fine urinary catheter No. 8 should be preset. In other words, the hepatoduodenal ligament and the right branch of portal vein were successively tied, the main trunk of portal vein was disconnected from the left branch, the diseased liver and cancer embolus were removed, the suction head continued to aspirate the residual cancer embolus through the broken end of portal vein, a catheter was placed, saline was flushed, the hepatoduodenal ligament ties were loosened, the main trunk of portal vein above the duodenum was controlled by the fingers, the fingers were relaxed, the blood flow from the stump was seen to be ejected to remove the residual cancer cells, and the The right branch of portal vein was blocked and the stump of the left branch of portal vein was continuously sutured with 4-0 prolene suture. HCC of the right lobe of the liver with right branch portal vein carcinoma thrombus is treated in the same way as HCC of the left lobe of the liver with PVTT. When the cancer thrombus of the left or right branch of portal vein extends to the trunk, the right or left branch of portal vein is separated and tumor of the left or right lobe of liver is removed, the stump of portal vein is clamped without suture, and the main trunk of portal vein is gently pinched by the left index thumb above the duodenum, and the stump of portal vein is released at this time, under the impact of portal vein pressure, the cancer thrombus is rushed out in strips with portal vein blood, and the head of suction device is inserted from the broken end of the left or right branch of portal vein to aspirate the main trunk. If the cancer embolus is tightly attached to the wall, it can be scraped with a spatula, then rinsed with saline and the broken end is sutured. When hepatocellular carcinoma of the right or left lobe of the liver was accompanied by the left and right branches of portal vein and trunk filled with cancer thrombus, portal vein cannulation (PVI) was performed in 5 cases after resection of hepatocellular carcinoma of the left or right lobe of the liver and PVTT, hepatic artery cannulation (HAI) in 9 cases, and double cannulation of hepatic artery and portal vein in 6 cases. Survival rate after surgery: 6 cases died of liver failure within 3 months after surgery, 2 of them died within 1 month after surgery, and the surgical mortality rate was 1.5%. 11 of 143 patients were lost after 3 months, and the survival rates of the remaining 132 patients were 45.8%, 29.1%, and 17.3% at 1, 2, and 3 years after surgery, respectively. Five of these cases have survived for more than 5 years. The advantage of aggressive surgical treatment is to remove the hepatocellular carcinoma and eliminate the carcinoma embolus at the same time by removing the portal vein in the hepatectomy section or directly cutting the portal vein with the carcinoma embolus, which theoretically can achieve better results. However, in practice, it is sometimes difficult to remove the cancer embolus, and the recurrence of the cancer embolus or microembolus spread within the liver is not satisfactory in the long term. The combination of chemotherapy can effectively improve the survival of patients. The overall survival rate after surgery was 48.5%. Konishi [5] reported 18 patients with hepatocellular carcinoma combined with portal vein thrombosis who underwent portal vein dissection and embolization at the same time of hepatic cancer resection, and the cumulative 1-year and 2-year survival rates were 48% and 34%, respectively. Asahara [6] et al. concluded that the prognosis of patients who underwent hepatic resection with embolization was significantly better than that of patients who underwent hepatic resection alone. It is believed that aggressive surgical treatment not only improves the survival and quality of life of patients, but also effectively prevents the serious complications of hepatocellular carcinoma combined with portal vein thrombosis, and it is believed that aggressive surgical treatment should be performed whenever conditions allow. Therefore, this procedure has the following advantages: (1) Removal of the primary cancer site prevents the cancer embolus from continuing to invade the portal vein. ②It can lower the portal vein pressure and reduce the risk of bleeding from ruptured esophageal varices. ③As a remedial measure to dislodge the cancer embolus into the portal vein during intraoperative hepatic cancer resection. ④To make the subsequent treatment such as hepatic artery embolization chemotherapy proceed smoothly and prolong the survival of patients. However, surgical treatment alone as a single treatment was more applied in the early exploratory stage of cancer embolism treatment, and no longer used alone with the deepening of understanding. 2.Hepatic tumor resection and portal vein embolization combined with transcatheter infusion chemotherapy is the most common pathological type of cancer embolism in clinical practice, and the effect of surgery alone is often unsatisfactory due to the close adhesion of the cancer embolism to the portal vein wall, which is not easy to remove. The median survival time in the surgical resection plus chemotherapy group was 13.4 months and six months after surgery. The median survival time in the conservative treatment group was 3.5 months; the median survival time in the chemotherapy group was 7.1 months; and the median survival time in the surgical resection group was 10.3 months; significantly higher than the other three groups (P<0.05). And it was considered that because microscopic cancer emboli and micro metastases existed before surgery. and could not be detected, which could easily lead to early recurrence of hepatocellular carcinoma after surgery and affect the efficacy, routine chemotherapy after resection of hepatocellular carcinoma and removal of carcinoma emboli was considered necessary.Fukuda [4] et al. observed 19 patients with carcinoma emboli in the inferior vena cava, portal vein and extrahepatic biliary tract and concluded that if the liver storage function was good, transcatheter perfusion chemotherapy after resection of hepatocellular carcinoma in patients with HCC with carcinoma emboli was feasible, and postoperative chemotherapy was administered according to Postoperative chemotherapy through portal vein cannulation is more effective than hepatic artery cannulation based on the pathological characteristics of the thrombus. Based on the resection of hepatocellular carcinoma and portal vein thrombectomy, the additional hepatic artery and portal vein double cannulation subcutaneous pump infusion chemotherapy not only removes the liver tumor and removes the portal vein cancer thrombus, but also plays an effective therapeutic role for the residual cancer foci and cancer thrombus through hepatic artery and portal vein double infusion chemotherapy, thus preventing the residual microscopic cancer thrombus from continuing intrahepatic dissemination and reducing recurrence, thus obtaining better near- and long-term curative effects. 3.Palliative hepatic artery and portal vein double-intubation chemotherapy is an effective treatment for patients with unresectable primary lesions and combined with PVTT in the middle and late stages. There are two methods of hepatic artery and portal vein double cannulation chemotherapy: one is to use open surgery for hepatic artery and portal vein double cannulation and subcutaneous buried drug injection pump chemotherapy; the other is to apply percutaneous transhepatic puncture selective portal vein embolization chemotherapy on the basis of hepatic artery embolization chemotherapy. Theoretically, dual perfusion embolization chemotherapy is superior to hepatic artery embolization chemotherapy alone, which can block the dual blood supply to both liver tumor and PVTT, and at the same time can expose PVTT directly to the high concentration of anti-cancer drugs to achieve the purpose of controlling liver tumor and eliminating cancer thrombus. Wang Xuan et al [8] combined B-ultrasound-guided percutaneous transhepatic selective portal vein chemoembolization with hepatic artery embolization chemotherapy in 38 patients with hepatocellular carcinoma combined with PVTT, and the disappearance and shrinkage rate of portal vein cancer thrombus was 68.4% and the tumor shrinkage rate was 76.3%; the 1-year and 3-year survival rates were 73.7% and 18.4%, respectively, which were much higher than that of the hepatic artery embolization chemotherapy treatment group alone. It is believed that double perfusion embolization chemotherapy is an effective method for treating hepatocellular carcinoma combined with PVTT and is superior to hepatic artery embolization chemotherapy alone. Yamakado et al [9] applied stent therapy to 21 cases of HCC combined with portal vein trunk cancer thrombus, which could improve gastroesophageal varices, reduce ascites and improve patient's survival, etc. Chan et al [10] combined TACE and percutaneous anhydrous alcohol injection (PEI). Chan et al [10] successfully treated a male patient with HCC combined with PVTT by combining TACE and percutaneous ethanol injection (PEI), and no tumor recurrence was observed at 18 months of follow-up. In conclusion, there is still no one suitable treatment for any patient, and the ideal approach is to apply surgical methods to remove the hepatocellular carcinoma and portal vein cancer thrombus, and to administer local liver chemotherapy or embolization chemotherapy after removal of the cancer thrombus, as well as biological therapy and other combined treatments to maximize survival.