Peripancreatic vascular dissection was proposed by academician Qiu Fazu, and has become the procedure of choice for the treatment of portal hypertension in China. Professor Yang Zhen has proposed selective peripancreatic vascular dissection through years of clinical practice, especially through anatomical studies of the peripancreatic vessels in the lower esophagus and gastric fundus. This procedure not only prevents and treats hemorrhage by disconnecting the varices in the lower esophagus and gastric fundus, but also maintains the spontaneous portal shunt by preserving the paraesophageal veins. 1.Anatomical basis of selective peripancreatic vascular dissection–paraesophageal and periesophageal veins The periesophageal vein belongs to the gastric branch of the left gastric vein. The gastric branch travels along the lesser curvature of the stomach toward the pylorus, connects with the right gastric vein, and sends several branches into the lower esophageal wall, the fundic wall and the anterior and posterior walls of the lesser curvature of the stomach. Paraesophageal vein is the upward branch of left gastric vein, which is generally called esophageal branch. The esophageal branch (paraesophageal vein) starts from the bulge of the gastric coronary vein at the esophagogastric junction, about 0.5 cm away from the esophageal wall and travels upward parallel to the esophagus. The left side of the vein emits four to six penetrating veins, which enter the esophageal wall in a vertical pattern and connect with the venous plexus in the esophageal wall. The paraesophageal vein passes upward through the esophageal fissure into the thoracic cavity and connects with the thoracic paraesophageal vein, then flows back into the inferior vena cava via the odd vein. The peresophageal and paraoesophageal veins are the main vessels outside the wall of the lower esophagus. There are multiple peresophageal veins located around the wall of the esophagus. The paraoesophageal vein is usually only one, about 0.5 cm away from the esophageal wall, and runs parallel to the upper esophagus. In portal hypertension, the paraoesophageal veins are heavily varicose and tortuous, and have extensive traffic branches with the veins in the retroperitoneum and lower esophagus and cardia fundus area, forming the paraoesophageal venous plexus. 2.The rationality of selective peripancreatic vascular dissection The paraesophageal vein starts directly from the left gastric vein and is one of the main branching vessels connecting the portal vein. Preserving the main trunk of the left gastric vein as well as the paraesophageal vein, disconnecting only the gastric branch of the left gastric vein and the branch into the gastric wall, and disconnecting the penetrating vein of the paraesophageal vein can not only block the abnormal blood flow of the abdominal segment of the esophagus, but also maintain the spontaneous shunt of the body and reduce the pressure of the portal vein. If the main trunk of the left gastric vein and the paraoesophageal vein are indiscriminately severed, the spontaneous shunt between the portal vein will be blocked and the portal vein pressure will be increased. High portal vein pressure not only increases the incidence of gastric mucosal lesions, but also promotes the formation of new collateral vessels in the esophagogastric fundus region, leading to the re-formation of varices and recurrent bleeding from variceal rupture. The main difference between this procedure and the traditional peripancreatic vascular dissection is that the main trunk of the left gastric vein and the paraesophageal vein are preserved, and only the gastric branch vein entering the gastric wall and the perforating vein entering the esophageal wall are dissected. The spontaneous formation of shunt between portal veins is a compensatory mechanism of the body, and its shunt flow is reasonable, appropriate and physiological, which can maintain the necessary blood flow into the liver while appropriately reducing the pressure of portal vein, thus achieving dynamic equilibrium, which is different from artificial splenic-renal venous shunt or portal-venous shunt, so it should be preserved. Since the spontaneous shunt of the organism is preserved on the basis of disconnection, the purpose of combined surgery of shunt and disconnection can be achieved. 3.Basic steps of selective peripancreatic vascular dissection Most of the steps of this procedure are the same as the classical non-selective peripancreatic vascular dissection, namely: ① perform total splenectomy, i.e. disconnect the short gastric vein; ② disconnect the left inferior diaphragmatic vein; ③ disconnect the posterior gastric vein; ④ dissect the anterior plasma membrane of the esophageal cardia area and disconnect the peripancreatic veins one by one. The branches of the left gastric vein and the accompanying branches of the left gastric artery are disconnected from the lower esophageal wall, the fundic wall and the anterior and posterior walls of the lesser curvature. The purpose is to preserve the integrity of the main trunk of the left gastric vein as well as the paraesophageal vein in order to ensure a partial shunt of portal blood through the coronary vein → paraesophageal vein → hemichoric vein. To further increase the spontaneous shunt flow in the organism, a large omentum covering the posterior peritoneum is also attached after the above steps are completed to establish a more extensive traffic branch between the portal veins through the perirenal and retroperitoneal collateral circulation. This, together with spontaneous shunting of the paraesophageal vein, moderately reduces the pressure in the portal vein, especially relieving the stasis in the gastric wall, and may reduce the incidence of gastric mucosal lesions. However, each patient is different and there are many variants, not all of them can preserve the paraesophageal vein, and if its trunk enters directly into the abdominal segment of the esophagus, it should still be disconnected. Sometimes the varices in the cardia area of the esophagus form a plexus or cluster of veins, and it is not easy to identify the beginning and course of the paraesophageal vein, and it is difficult to disconnect the penetrating vein.