In our country, liver cirrhosis caused by various reasons is a common disease, especially post hepatitis cirrhosis, the incidence rate is still very high, with the progression of cirrhosis, the patient will develop portal hypertension, which will lead to rupture and bleeding of esophagogastric fundal varices, which is life-threatening. Therefore, the treatment of portal hypertension is of great importance. Currently, surgical treatment includes surgical treatment and interventional treatment. The former includes various kinds of shunt surgery and disconnection surgery between portal veins, liver transplantation, and the latter includes transjugular intrahepatic portal shunt, gastric coronary vein embolization under intervention, splenic vein embolization, and so on. This article summarizes the problems related to the surgical treatment of portal hypertension as follows. I. Overview The portal vein blood flow back into the liver, when the portal vein blood flow back into the liver is blocked, the pressure of the portal vein and its subordinate branches of the pathologically elevated, called portal hypertension. The main clinical manifestations of portal hypertension include splenomegaly and hypersplenism, pericardial varices and rupture and bleeding, ascites, portal hypertensive stomach, spontaneous peritonitis and so on. Modern surgical treatment of portal hypertension began in the 1950s, and from the 1950s to the 1960s, various surgical methods were tried, including shunt surgery and interruption of flow, and some clinical experience was accumulated; from the 1970s to the 1980s, it was mainly a debate about the advantages and disadvantages of shunt surgery and interruption of flow, which had their own merits and demerits, and one of them couldn’t replace the other; after the 1980s, some new treatments have been developed, such as interventional hepatic venous hypertension, and the development of interventional hepatic venous hypertension. After the 1980s, some new treatment methods have been developed, such as interventional hepatic-portal vein shunt, liver transplantation, laparoscopic splenectomy, and flow-breaking surgery. Secondly, the way to cut off the flow and its advantages and disadvantages Cutting off the flow generally refers to cutting off the varicose blood vessels around the cardia, which usually includes splenectomy. There are several ways.In 1967, Hassab proposed splenectomy and pericardia de-vascularization, i.e. Hassab’s operation: including splenectomy, pericardia vascular dissections, ligation of left gastric artery, vagus nerve severance, pyloroplasty. This procedure is an earlier way of cutting off the flow and obtains certain results, but it requires resection of the vagus nerve and pyloroplasty, which interferes with the function of the stomach in the postoperative period. During the same period, Sugiura of Japan proposed the Sugiura operation, i.e., combined transthoracic-abdominal flow amputation: transthoracic dissection of all collateral blood vessels of the esophagus below the lower pulmonary vein, transection of the esophagus and then anastomosis, transthoracic splenectomy, dissection of all collateral blood vessels of the esophagus from the upper half of the stomach to the diaphragm, severing of the vagus nerve, pyloroplasty, and preservation of the left gastric trunk and parietal esophageal vein. This procedure is complete and effective in stopping hemorrhage. However, due to the combined thoraco-abdominal incision, the operation is very traumatic, and due to the incision of the esophagus or fundus of the stomach, it is easy to contaminate the thoracic and abdominal cavities, which causes serious infections, and it is prone to anastomotic leakage and esophageal stenosis, etc. The mortality rate of the operation is also high. Since then, there is a modified Sugiura surgery: no longer perform transthoracic surgery, it is to complete splenectomy via abdomen, and use anastomosis to complete esophageal transverse anastomosis at 2cm above cardia, and still retain the left gastric vein trunk and parietal esophageal vein. Domestic scholars usually do not perform pyloroplasty when doing modified Sugiura. This procedure is significantly less traumatic and has fewer complications than Sugiura.In 1981, Prof. Qiu Fazu made an in-depth study on Hassab procedure and portal hypertension, and put forward the importance of high esophageal branch of coronary vein, high ectopic esophageal branch, and retrosternal gastric vein in the treatment of portal hypertension, pointing out that these veins should be more thoroughly cut off in the weaning, emphasizing on the dissection of the vessels of the lower esophagus for 6-8cm, thus forming the basis of our pancreatic surgery and the treatment of cardia. This led to the formation of our pericardia vascular dissection, which has been proved to be reliable in hemostasis and with few complications, and has gradually become the standard dissection surgery in China. The combined dissection is actually a modified Sugiura or on the basis of pericardia vascular dissection, blocking the abnormal blood flow in the lower esophagus, gastric fundus muscularis and submucosal layer, which is a transverse esophageal dissection and anastomosis with an anastomosis 2 cm above the cardia in the lower esophagus, which further improves the thoroughness of dissection and has a better long-term efficacy of preventing recurrence of varices and/or rupture and hemorrhage. However, the portal vein pressure on the gastric side may be higher after this procedure, which may aggravate or induce portal hypertensive gastropathy, and complications such as esophageal leakage and esophageal stricture are likely to occur after this procedure. Yang Shen, a scholar in China, proposed selective peripancreatic vascular dissection. The main point of this surgery is to preserve the main trunk of the left gastric vein and the parietal esophageal vein when disconnecting the flow, and only cut off the perforating branches of these blood vessels into the fundus of the stomach and the lower esophagus, with the purpose of making part of the left gastric vein blood flow back into the vena cava through the parietal esophageal vein and then through the hemi-cheeky vein, so as to reduce the portal vein pressure. This procedure theoretically helps to improve portal pressure, but whether it would tend to lead to vascular regeneration, or varicose or aggravated peri-esophageal veins on the diaphragm, which in turn could lead to bleeding, deserves further investigation. In conclusion, the rationality of flow-rupture is shown in the following: firstly, it is directly cutting off the peripenic varices, directly acting on the bleeding area, with exact hemostatic effect, and the surgical operation is relatively simple. Secondly, after cutting off the flow, the pericardia interportal vena cava traffic branch is blocked, and the blood flow of portal vein will be increased, which ensures sufficient blood supply to the liver, which is conducive to the improvement and maintenance of liver function, and is beneficial to the prevention and treatment of hepatic encephalopathy. Of course, the shortcoming of this procedure is that portal vein pressure pain usually increases further after the flow is cut off, which may affect the reflux in the mesenteric vascular region and may further aggravate ascites. At the same time, there is a risk of exacerbation of portal hypertensive gastropathy. In addition, postoperative splenic vein thrombosis is likely to occur after the weaning procedure, which in turn has the potential to carry over into the portal vein and superior mesenteric vein, and in severe cases, can result in life-threatening bruising and necrosis of the small intestine. Postoperative rebleeding is also a major problem with flow-disconnecting surgery. After weaning, the pressure in the portal vein increases, which may result in the re-establishment of collateral circulation and the formation of new variceal hemorrhage. If there is incomplete weaning with missed branches of varices, or if there are venous traffic branches in the muscular and or submucosal layers of the gastric wall, the pressure in these vessels will be even higher and more likely to cause rebleeding. Therefore, shunt surgery must completely cut off the traffic branch vessels in the operation area, and has achieved the effect of less re-bleeding. Third, shunt surgery methods and advantages and disadvantages Shunt surgery is more applied in foreign countries, and the main surgical methods are as follows. Portal shunt: including lateral shunt of portal cavity, end side shunt of portal cavity, inter-portal H-type shunt, etc. The first two ways are to make portal vein shunt, and the second way is to make portal vein shunt. The first two ways are to make the portal blood flow back into the vena cava quickly, with significant reduction of portal pressure and good hemostatic effect, but it will seriously reduce the portal blood supply, leading to further damage of hepatocyte function and deterioration of liver function, in addition, a large amount of portal blood directly enters into the body circulation, and the incidence of hepatic encephalopathy is increased and serious. The latter is actually possible in bridge shunt, which can limit the size of the shunt port at the place of bridging, thus striking a balance between lowering the portal pressure and ensuring the blood supply to the liver, which is advantageous over the first two ways. Proximal splenorenal vein shunt: It is to remove the spleen and anastomose the broken end of the splenic vein with the left renal vein. This procedure removes the spleen, which can treat hypersplenism, shunts part of the portal vein blood flow to the vena cava, which reduces the portal pressure, and achieves the effect of relieving portal hypertension in the gastrosplenic area and treating peripancreatic varicose veins and hemorrhage. However, the anastomosis is small and prone to thrombosis, affecting the shunt effect. Distal splenorenal shunt, also known as Warren’s operation, is about 1cm from the beginning of portal vein, cutting off the splenic vein, proximal ligation, distal anastomosis with the left renal vein, and at the same time, cutting off and ligating the inferior mesenteric vein, cutting off the small vein between the splenic vein and the pancreas. This is a selective shunt surgery, which can reduce the pressure of portal vein in the gastrosplenic region and achieve the purpose of treating pericardial variceal hemorrhage. Cutting off the blood vessels between pancreas and splenic vein is due to the existence of the traffic branch of the superior mesenteric vein system and the splenic vein system in the region of the pancreas, when the pressure of the splenic vein decreases, the blood flow of the superior mesenteric vein can enter into the splenic vein through the syphonization effect of the pancreas, which will reduce the selective shunt effect. In effect, it is a splenorenal shunt plus pancreaticosplenic interruption. This procedure selectively reduces regional portal pressure while ensuring portal blood supply, protecting hepatocyte function and reducing the incidence of hepatic encephalopathy. Intestinal luminal shunt: including lateral anastomosis between superior mesenteric vein and inferior vena cava, artificial blood vessel bypass between superior mesenteric vein and inferior vena cava to form an H-type anastomosis, these procedures are partially shunt the portal vein blood flow and reduce the portal venous pressure, but it involves the anastomotic size control, the use of artificial blood vessels, the surgical method is slightly complicated, and is not a direct reduction in the gastrosplenic region of portal hypertension, so the effectiveness of the treatment needs to be observed. Coronary vena cava shunt: this procedure involves freeing the coronary vein and inferior vena cava, bridging or directly anastomosing between the two, and shunting the blood flow from the coronary vein to the inferior vena cava. This procedure highly selectively shunts the blood flow of the portal vein belonging to the branch of the portal vein in the gastric region, reduces the portal pressure in this region, and treats varicose vein hemorrhage, which is theoretically reasonable, and maximizes the portal perfusion, which is beneficial to the maintenance of the hepatic function. In conclusion, the advantage of shunt surgery is to reduce portal vein pressure and treat pericardial variceal hemorrhage at the same time it is also helpful to improve portal hypertensive gastropathy and intractable ascites. The disadvantage is that the hepatic blood supply is reduced after shunt, and the liver function may further deteriorate, in addition, the direct inflow of portal vein blood flow without hepatic treatment into the body circulation will lead to the occurrence and aggravation of hepatic encephalopathy. Therefore, our scholars also proposed to apply the combined application of shunt surgery, which can give play to the advantages of the two procedures, but at the same time, the surgical trauma increases, and for patients with cirrhosis, the risk increases. Fourth, liver transplantation for portal hypertension At present, liver transplantation for end-stage liver disease has made great progress. Whether it is flow-cutting surgery, or shunt surgery, neither can solve the root cause of cirrhosis, so neither can solve the basic cause of portal hypertension. Liver transplantation, on the other hand, is able to resolve cirrhosis and thus treat the underlying cause of portal hypertension. Liver transplantation is complex, traumatic, requires maintenance of immunosuppressive therapy after surgery, and the shortage of donors is the biggest obstacle limiting its widespread use. Therefore, liver transplantation for the treatment of portal hypertension requires strict control of the indications. Commonly used methods for assessing the timing and risk of liver transplantation in patients with end-stage liver disease are Child-Pugh score or MELD score. The former needs to determine the degree of hepatic encephalopathy and ascites, which is subjective, and the MELD score is mostly used nowadays, which has obvious advantages as a new evaluation system, and it helps to accurately select the timing of transplantation and predict the prognosis. The United States United Network for Organ Sharing (UNOS) has enabled the MELD model score as the basis for organ allocation, and liver transplantation is considered when the MELD score is greater than 20. In addition, due to the scarcity of liver sources, when performing surgical treatment for non-liver transplantation, the harassment of the hepatic hilum should be minimized as much as possible, so as to leave room for liver transplantation in the future. V. Laparoscopic and interventional treatment of portal hypertension In recent years, with the development of laparoscopic technology, laparoscopic technology has been gradually adopted in the treatment of portal hypertension. At present, there are mainly laparoscopic splenectomy and peripancreatic vascular dissection, the operation is less traumatic, but the operation is more difficult, the reason is that cirrhosis leads to more varicose veins in the operation field, in addition, the spleen is mostly enlarged or even giant spleen, and the coagulation function of patients with cirrhosis is poor, which is not conducive to surgical operation. Laparoscopic splenectomy and portal vein amputation is technically feasible, but the indications for surgery need to be strictly controlled, good surgical conditions need to be available, the timing of surgery needs to be well grasped, and it must be carried out by physicians with rich experience in laparoscopic surgery in order to avoid the possibility of hemorrhage in the intra-operative period and postoperative period. Interventional treatments for portal hypertension include transjugular intrahepatic portosystemic shunt (TIPS), varicose coronary vein embolization, and splenic artery embolization.TIPS is more effective in controlling acute bleeding, and it reduces the portal pressure after the operation, which helps to reduce ascites and improve the varicose veins. However, the shunt effect is affected in the long term due to the narrowing or obstruction of the shunt tract. Currently, it is mainly used in the acute state, and the less invasive TIPS treatment can be considered for patients with poor liver function who are difficult to tolerate surgery. Varicose coronary vein embolization cannot solve the problem of increased portal vein pressure, and it is more difficult to accurately embolize to the bleeding site, which limits its application in the clinic. Splenic artery embolization is prone to complications such as splenic infarction, splenic necrosis and splenic abscess, and some splenic artery embolization has little effect on lowering portal vein pressure; these methods need further clinical observation and research. Prospect At present, the surgical treatments for portal hypertension have their own advantages and disadvantages, and it is difficult to replace other treatment modalities with one modality. In the future, it is also necessary to accumulate more evidence based on symptomatic medicine in order to compare the methods that will make the patients more profitable, less traumatized, with fewer complications, and with better long-term results. The pathogenesis and hemodynamic changes of portal hypertension are complex, and it is only with the deepening of basic research that better theoretical support for clinical surgical treatment may be provided. Surgical treatment of portal hypertension in liver cirrhosis has made great progress after decades of development. At present, the status of surgical treatment is irreplaceable, and the surgical modality is still mainly based on flow-disconnecting surgery and shunt surgery, and patients who are eligible for liver transplantation can consider active liver transplantation, and laparoscopic surgical treatment needs to strictly grasp the indications to ensure safety, and minimally invasive interventional therapy can be used as a supplement to traditional surgery, and applied to some patients with acute diseases. Minimally invasive interventional therapy can be used as a supplement to traditional surgery and applied to patients with some acute diseases.