Anatomic variation of the right hepatic artery and its reconstruction for living donor liver transplantation using right lobe graft

We analyzed the anatomy and reconstruction of the right hepatic artery (RHA) in 96 cases of adult-to-adult living donor right liver transplantations, during 2002. Most right livers had a single orifice (n = 185, 96%). Seven right livers (4%) showed multiple arteries, namely a replaced artery in five cases and accessory arteries in two cases. Three liver grafts had two separate orifices: both arterial stumps were reconstructed in one case, and accessory arteries were ligated in two cases because of sufficient back bleeding. The mean diameter of the graft RHA was 2.4 mm (1-4). More than 60% (59 of 96) of graft arteries were anastomosed with distal branches of recipient RHA for size matching. Eleven graft arteries were anastomosed to vessels other than the RHA, namely the left hepatic artery [LHA] in eight right gastroepiploic artery in three: for size matching in five and due to previous injury of RHA in six. Five cases showed significant size-mismatches of more than twofold. The median follow-up period was 270 days. In one patient, an intramural thrombus developed on postoperative day 3 requiring a revision of the anastomosis. In another patient, arterial stenosis occurred on postoperative day 16 a time when collateral arteries had developed. The overall complication rate related to arterial reconstruction was 2%. In conclusion, with precise knowledge of the anatomy, an adequate selection of recipient arterial stump, and an experienced technique, a desirable result may be achieved in right lobe transplantation.     

Traumatic and postoperative ischemic liver necrosis: causes, risk factors and treatment

BACKGROUND: To study the cause and outcome of ischemic liver necrosis and suggest treatment of these patients. METHODS: Retrospective study of 13 patients with ischemic liver necrosis treated at our departments from 1990 until 1997. RESULTS: Ischemic liver necrosis was caused by general hypoxia (n = 1) or acute arterial occlusion (n = 12) of the celiac and superior mesenteric artery (SMA, n = 3), proper hepatic artery (PHA, n = 1), right hepatic artery (RHA, n = 2), left hepatic artery (LHA, n = 2) and intrahepatic vessels (n = 4). Six of the cases were related to surgical procedures, 5 of these (38%) were unintended arterial injuries after biliary surgery. Ten patients (77%) had risk factors contributing to the development of liver necrosis: septicemia (n = 4), jaundice and septicemia (n = 2), shock and hypoxia (n = 3) and alcoholic cirrhosis (n = 1). Five patients (38%) needed resection of the liver necrosis due to infected necrosis. Three patients (23%) died; two of these had celiac/SMA occlusion. One died due to complete gastrointestinal ischemia and severe lactacidosis, two died of multiorgan failure after bile leakage and septicemia. CONCLUSION: Ischemic liver necrosis is mainly caused by arterial occlusion due to arteriosclerosis, arterial transection during biliary surgery or blunt liver trauma, and seldom occurs without additional risk factors. 50% of the patients develop infected necrosis and need liver resection. Patients with sterile necrosis may recover without surgical procedures of the liver. The mortality in patients with central (celiac/SMA) and peripheral (CHA, PHA, RHA, LHA, intrahepatic branches) occlusions was 67% (2/3) and 11% (1/9), respectively.     

肝门胆管癌根治术中用胃十二指肠动脉行肝动脉重建

目的 总结胃十二指肠动脉代替肝动脉重建在肝门部胆管癌根治术中的应用经验.方法 回顾性分析2004-2008年9例肝门部胆管癌根治术中,胃十二指肠动脉代替肝动脉重建临床资料及随访结果.结果 9例行肝门部胆管癌根治术肝动脉切除超过1 cm,利用胃十二指肠动脉代替肝动脉进行重建,其中1例联合门静脉部分楔形切除,自身大隐静脉移植修复,8例行肝内胆管支撑.9例术后全身炎症反应综合征于2～3 d后明显缓解,1例术后3 d出现上消化道出血治愈,无手术死亡和住院死亡.术后2周彩色超声临测显示重建肝动脉通畅.9例随访1～4年,中位生存期为23(6～32)个月.结论 胃十二指肠动脉能较好地代替肝动脉重建,减少术后并发症的发生.     

Diagnosis and treatment of hepatic artery stenosis after orthotopic liver transplantation

PURPOSE: The purpose of this study was to evaluate the accuracy of Multidetector Computed Tomographic Angiography (MDCTA) to detect hepatic artery (HA) stenosis after orthotopic liver transplantation (OLT) and the efficacy of treatment using percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: Twenty-two consecutive patients with OLT underwent MDCTA for evaluation of HA, followed by digital subtraction angiography (DSA) (gold standard). Source images (Ax) were processed, obtaining multiplanar reformations (MPRs), maximum intensity projections (MIPs), and volume renderings (VRs). Images were evaluated to identify the following: (1) arterial depiction (celiac axis, anastomosis, and left [LHA] and right [RHA] HA), (2) detection of stenoses, and (3) grading of stenoses. Indications for PTA were set at MDCTA and DSA, and PTA was performed when appropriate. RESULTS: MDCTA depicted the celiac axis and anastomoses in all patients; LHA and RHA were visualized in 21 of 22 patients with Ax, MPRs, and MIPs, and in 17 of 22 with VRs. All reconstruction modalities enabled correct diagnosis of celiac (n = 3) and anastomotic stenoses (n = 14). Of 6 LHA and RHA stenoses, 4 (66.7%) were visualized with Ax, MPRs, and VRs, and 5 (83.3%) were visualized with MIPs. Stenosis was overestimated in 9 (39.1%) cases with VRs and in 3 (13%) with the other modalities. PTA was performed in 8 cases, with 1 case of arterial dissection requiring re-OLT. At a median follow-up of 28 months, the primary and secondary patency rates were 71.4% (5 of 7) and 85.7% (6 of 7), respectively. CONCLUSIONS: MDCTA and accurate postprocessing enable confident depiction of the arterial anatomy and detection of stenosis after OLT. PTA is safe and allows allograft saving, at least until another suitable donor becomes available.     

Innovative technique to reconstruct two branches of the right hepatic artery in living donor liver transplantation

Hepatic arterial thrombosis is a critical complication in living donor liver transplantation (LDLT). Two separate branches of the right hepatic artery (RHA) are sometimes observed and addressed by anastomosis of the larger branch first, then checking backflow from the smaller branch. If not good, the smaller branch must be reconstructed. We used the cystic artery as a conduit for the reconstruction. Meticulous dissection was performed to identify all branches of the hepatic artery in the donor operation. The length of cystic artery preserved was as long as possible. The cystic arterial stump was anastomosed to the stump of the posterior branch the of RHA under microscopic guidance on the back table. Patency was checked through the stump of the anterior branch of the RHA. With this technique, only one orifice, the stump of right anterior hepatic artery, was used for hepatic artery reconstruction. We have performed this technique in two patients. Both had good arterial flow after living donor liver transplantation. This innovative technique is easy and safe, and requires only one anastomosis, which, in theory, decreases the adds of developing hepatic arterial thrombosis.     

大鼠肝移植重建肝动脉对胆管超微结构和并发症的影响

目的 观察大鼠原位肝移植重建肝动脉对肝内胆管上皮细胞缺血再灌注损伤后超微结构及术后胆道并发症的影响.方法 228只SD大鼠分为假手术组(8只)、肝移植重建肝动脉组(55对)和未重建肝动脉组(55对).重建肝动脉组和未重建肝动脉组分别于肝脏复流后0.5、3、6、12、24、36、48 h取材,用透射电镜观察肝内胆管上皮细胞的超微结构,通过计算机图像分析系统对线粒体形态计量分析;观察术后胆道并发症.结果 两组肝内胆管上皮细胞损伤均有加重,表现为线粒体肿胀、嵴模糊或消失、微绒毛减少等超微结构改变,至24 h达高峰,以后逐渐恢复.术后两组线粒体平均面积和周径随时间的延长逐渐增大,线粒体数密度随时问延长而减少.在24 h,两组缺血再灌注损伤最显著,之后均开始缓解.在24、36、48 h,两组线粒体平均面积、平均周径比较,差异均有统计学意义(t=-3.566,-7.780,-4.730,-4.610,-2.599,-5.370,P＜0.05);在36、48 h,两组线粒体平均数密度比较,差异有统计学意义(t=-4.619,4.000,P＜0.05).重建肝动脉组的胆道并发症发生率低于未重建肝动脉组(x2=4.286,P＜0.05).结论 大鼠肝移植重建肝动脉对肝内胆管上皮细胞缺血再灌注损伤后的超微结构具有保护作用,有利于术后恢复和减少胆道并发症的发生.     

肝动脉外科解剖在肝动脉置管术中的应用及意义

目的 目前术中肝动脉置管术(IHAC)已广泛应用于肝脏恶性肿瘤的综合治疗，但多采用盲目插管的方法，影响了IHAC的疗效。通过术中肝动脉的外科解剖结合肝动脉造影，了解肝总动脉及其主要分支的行径及相互关系，证明肝动脉外科解剖在IHAC中的意义。方法 采用电凝锐性解剖技术对116例肝脏或胆道疾病患者行肝动脉外科解剖，详细记录肝总动脉(CHA)、肝固有动脉(PHA)、肝左、右动脉(LHA、RHA)及胃十二指肠动脉(GDA)的位置和相互间的成角(锐角或钝角)，并在术中观察自然状态下导管经胃网膜右动脉插入后的走向。部分病例结合肝动脉造影资料进行分析。结果 (1)GDA与CHA呈水平或钝角72例(62％)。其中20例行IHAC，导管经胃网膜右动脉插入时全部进入CHA；(2)GDA与CHA呈锐角，而与PHA呈水平或钝角36例(31％)，13例行IHAC，导管或进入PHA或RHA；(3)PHA缺如8例(7％)。此外，116例中RHA起源于肠系膜上动脉9例(7．7％)，肝左动脉源于胃左动脉7例(6．0％)，肝左、右动脉之间在肝门部存在明显异常交通支2例(1．7％)。结论 影响IHAC准确性的关键是GDA与CHA的成角，以及肝动脉解剖异常。由于绝大多数GDA与CHA成角为钝角，加上一定比例的肝动脉解剖异常，因此，非肝动脉外科解剖的盲目插管其成功率不足25％，应引起临床的高度重视。     

Back-table arterial reconstructions in liver transplantation: single-center experience

Anatomic variations of the arterial supply to donor liver grafts often require complex hepatic artery reconstructions on the back table. Therefore, because of the additional anastomoses, there is a greater risk of arterial thrombosis and graft loss. Among the 620 orthotopic liver transplantations (OLT) in 549 adult and pediatric patients performed from June 1983 through August 2004, the rates and types of donor hepatic artery variations (HAV) and the type of reconstructions were reviewed as well as the 1- and 5-year grafts and patient survival rates after OLT. At least 1 HAV was present in 133 liver grafts (21.4%). The most frequent variations were as follows: right hepatic artery (RHA) from superior mesenteric artery (SMA) (44 cases); RHA from aorta (4 cases); and RHA from SMA, combined with a left hepatic artery (LHA) from left gastric artery (3 cases). No graft was discarded. Fifty-six of 133 (42%) HAV required arterial reconstructions, generally a termino-terminal (TT) anastomosis between RHA and splenic artery (26 cases, 46.4%). Less frequently performed anastomoses were the "fold-over" technique (15 cases, 26.8%) and the anastomosis between the RHA and the gastro-duodenal artery (6 cases, 10.6%); rare reconstructions were performed in 9 cases (16.0%). The rate of hepatic artery thrombosis was 5.4% (3 of 56 OLT) in complex hepatic artery reconstructions and 2.2% in other grafts. One- and 5-years graft and patient actuarial survival rates have been respectively 73.2%- 71.4% in hepatic artery reconstructions and 78.6%-76.8% in the absence of an artery reconstruction, respectively.     

原位肝移植供肝动脉变异的修整与重建

目的 探讨原位肝移植供肝动脉变异的修整与重建的方法与技巧. 方法 回顾性分析91例原位肝移植供肝修整以及变异肝动脉重建时处理的方法和技巧.结果 修整的91例供肝全部用于肝移植.发现其中20例(21.9%)存在肝动脉解剖变异,20例中12例需行变异肝动脉重建,动脉重建方法包括将变异的肝右动脉与脾动脉(7/12)或胃十二指肠动脉(5/12)吻合.供肝应用后未出现与修整相关的手术并发症. 结论 供肝的正确修整及合适的供肝动脉重建可减少肝移植后并发症.     

A modified technique for hepatic artery reconstruction in living donor liver transplantation

Reconstruction of the hepatic artery (HA) is challenging, because there are technical difficulties. Especially, it is difficult to repair the posterior wall. In 2006, we reported an experimental study of the posterior wall first continuous suturing combined with the interrupted suturing and we also confirmed the safety of this procedure. In this article, we report our clinical experiences using this procedure for the HA reconstruction in living‐donor liver transplantation. First, we repaired the posterior wall of the HA with continuous suturing. Then, the anterior wall is repaired with the interrupted suturing using a nylon suture with double needle. Between 2006 and 2009, we performed 13 HA reconstructions using our procedure. In all patients, the HA reconstruction was completed easily and uneventfully without oozing from the posterior wall or postoperative HA thrombosis. Our procedure has the benefits of both continuous and interrupted suturing. We believe that it is useful for reconstruction of the HA in living‐donor liver transplantation. © 2010 Wiley‐Liss, Inc. Microsurgery 30:541–544, 2010.     

动脉造影初步分析肝脏Ⅸ段肿瘤肝动脉血供

目的 研究肝脏Ⅸ段肿瘤的肝动脉血供方式.方法 回顾性分析8例肝脏Ⅸ段肿瘤病例的CT和DSA资料,由CT做出定位诊断,在DSA上观察肝脏Ⅸ段肿瘤的肝动脉血供情况.观察肝动脉的各级分支,统计这些分支向病灶供血的例数,分析肝脏Ⅸ段肿瘤的肝动脉血供来源.根据病灶染色情况,以积分法确定这些肝动脉分支向病灶供血的多少.结果 肝脏IX段肿瘤的肝动脉血供来源十分广泛,MHA、RPHA、RAHA、LMHA和CallA向病灶供血的例数分别是7、6、5、5和2例(X2=2.800,P=0.592,Chi-square test),积分分别是15、13、11、6和2分(X2=9.657,P=0.047,Kendall's W).RHA和LHA的积分分别是38和9分(Z=-2.243,P=0.025,Wilcoxon).未见CyA和LLHA向病灶供血的病例.结论 RHA和LHA系统都有可能向肝脏Ⅸ段肿瘤供血,RHA供血比LHA多.MHA、RPHA、RAHA、LMHA是主要的供血支.     

供肝动脉变异和植入前动脉重建

目的探讨供肝动脉变异类型,术中损伤原因及植入前重建的方法。方法1993年10月至2004年12月,中山大学附属第三医院肝脏移植中心共行供肝切取和修整术600例,术中记录肝动脉变异类型和术中动脉误伤,重建变异肝动脉,形成单一的备吻合血管。结果在600例供肝中,19·2%(115/600)供肝动脉变异。53例(53/600)变异动脉须血管重建,其中39例(39/53)代替性或副肝右动脉来自肠系膜上动脉,1例(1/53)代替性肝右动脉来自腹腔干,5例(5/53)代替性或副肝左动脉来自胃左动脉,2例(2/53)变异肝左动脉和3例(3/53)变异肝右动脉离断后来源不清,3例(3/53)变异肝左和肝右动脉双重替代。6例(6/485)供肝切取术中意外损伤正常肝动脉,需要动脉重建。变异肝动脉损伤19例(19/115),均行动脉重建。动脉重建方法包括变异动脉与脾动脉(36/53)、胃十二指肠动脉(12/53)以及复杂的吻合方法(5/53)。结论供肝快速切取过程中,肝动脉变异增加肝动脉意外损伤发生率,损伤变异动脉均须在植入前重建。变异动脉重建方法的选择取决于肝动脉解剖学特点。     

合并肝动脉切除重建的肝门部胆管癌根治术

目的观察肝动脉切除重建在肝门部胆管癌治疗中的价值。方法1998年1月至2005年12月计收治125例肝门部胆管癌，其中行肝动脉切除13例，对该资料进行分析。结果在行肝动脉切除13例中，同时合并门静脉切除重建3例，其中部分肝固有动脉＋右或左肝动脉切除联合左或右半肝及尾状叶切除10例，局部切除联合肝固有动脉切除1例，部分肝固有动脉＋右或左肝动脉切除联合扩大左或右半肝及尾状叶切除各1例，肝动脉切除后未重建2例。术后胆肠吻合口漏4例，围手术期肝功能衰竭死亡1例，其余12例病人术后随访4个月至6年，平均20个月，其中最长的1例已存活5年5个月。结论肝动脉切除重建可提高肝门部胆管癌的治愈切除率，改善术后病人预后；肝脏大部切除联合肝动脉切除在中、重度黄疸病人须重建动脉血供。     

En bloc resection of the hepatoduodenal ligament for advanced carcinoma of the biliary tract]

Theoretically, en bloc resection of the hepatoduodenal ligament is considered to be the most radical procedure for advanced carcinoma of the biliary tract. However, this procedure involves perioperative difficulties such as hepatic ischemia, portal congestion, patency of reconstructed vessels, and high incidence of operative mortality, moreover, when it is combined with resection of the liver and/or pancreas. We developed several tactics in vascular reconstruction, hepatic resection, and pancreatoduodenectomy in order to decrease the operative morbidity and mortality. We preferred to anastomose the portal vein and hepatic artery separately to avoid total hepatic ischemia, and used the porto-systemic bypass during prolonged portal reconstruction. We resected the liver without vascular clamping to minimize hepatic ischemia, and employed the simplified method of pancreatojejunostomy. To date, we performed 4 hepatoligamentectomies and 4 hepatoligament-pancreatoduodenectomies with no operative mortality, although long-term survivors were not encountered. This procedure should be evaluated with more clinical experiences after its safety and indication was established.     

肝移植供体切取中变异肝动脉的保护

目的 探讨在肝移植供体切取过程中如何避免损伤变异肝动脉。资料与方法 分析123例供肝切取资料，统计变异肝动脉发生率。结果 肝动脉解剖变异32例（26．02％），其中仅肝右动脉（RHA）变异11例（8．94％），仅肝左动脉（LHA）变异10例（8．13％），左右肝动脉均变异3例（2．44％），肝总动脉（CHA）起于肠系膜上动脉7例（5．69％），其它少见类型1例（0．81％），为肝固有动脉（PHA）来源于胃左动脉。结论 肝动脉解剖复杂，熟悉肝动脉解剖变异可减少供肝切取过程中的肝动脉损伤。     

The use of left grafts with a replaced or accessory left hepatic artery in adult‐to‐adult living donor liver transplantation: analyses of donor and recipient outcomes

In living donor liver transplantation (LDLT), a left hepatic graft occasionally includes a replaced or accessory left hepatic artery (LHA). The procuring of such grafts requires extensive dissection along the lesser curvature of the stomach to elongate the replaced or accessory LHA on the donor side. On the recipient side, complicated arterial reconstruction is often necessary to use such grafts. We retrospectively reviewed the medical records of 206 adult recipients who underwent LDLT and their respective donors. The recipients and donors were divided into two groups according to the presence of the replaced or accessory LHA. Twenty‐five grafts included a replaced or accessory LHA. Only one hepatic artery‐related complication was observed in the current series, in which a pseudoaneurysm arose at the site of anastomosis between the donor accessory LHA and the recipient LHA. There was no increase in the incidence of postoperative complications in the donors with a replaced or accessory LHA in comparison with the donors without these arteries. The use of left hepatic grafts that included a replaced LHA or accessory LHA did not have any negative impact on the outcomes on either the donor or the recipient side.     

小鼠肝移植中两种肝动脉重建方法的比较

目的比较小鼠肝移植中两种不同肝动脉重建方法的效果。方法应用雄性C57BL/6小鼠建立小鼠肝脏移植模型,随机分为肠系膜上动脉重建组（14对）和腹主动脉重建组（16对）。手术采用异氟醚吸入麻醉。供肝经门静脉灌注4℃威斯康星大学保存液（UW液）。两组小鼠的肝动脉重建分别采用供体肠系膜上动脉或供体肾下腹主动脉与受体腹主动脉端侧吻合两种方法。移植肝血流恢复后重建肝动脉。胆管采用内支架管的方法重建。观察术后2周移植物的存活情况和肝动脉通畅与否。用组织病理学方法检查移植肝的组织形态变化,用免疫组织化学法观察肝脏再生功能。结果术中无小鼠死亡,手术成功率为100%。肠系膜上动脉重建组供体肝动脉游离时间为（12.1±2.5）min,腹主动脉重建组为（17.3±3.1）min,比较差异有统计学意义（P〈0.05）。腹主动脉重建组肝动脉吻合时间为（14.5±2.9）min,肠系膜上动脉重建组相应为（12.4±3.3）min,比较差异无统计学意义（P〉0.05）。肠系膜上动脉重建组移植物术后2周存活率为93%（1只死于吻合口血栓形成）,腹主动脉重建组为100%。肠系膜上动脉重建组术后2周肝动脉通畅率为86%,腹主动脉重建组为100%。组织病理学检查示两组的移植肝组织正常,肝脏再生反应不明显。结论小鼠肝移植中,与应用肠系膜上动脉重建比较,应用腹主动脉吻合重建肝动脉的效果更好且安全,建议首选供受体腹主动脉吻合重建小鼠肝动脉的方法。     

Aberrant right hepatic artery in laparoscopic cholecystectomy.

INTRODUCTION: Presented herein is a case in which an aberrant right hepatic artery (RHA) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry. CASE REPORT: A 54-year-old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy. Laparoscopic dissection revealed an aberrant right hepatic artery (RHA) anterior to the infundibulum and fundus of the gallbladder. Further dissection revealed the cystic artery to branch laterally off this RHA over the gallbladder fundus anteriorly. The cystic artery then wrapped posterolaterally on the gallbladder's surface to its neck. After the gallbladder was removed, the aberrant RHA was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location. Intraoperative images are included. The procedure was completed laparoscopically without complication. DISCUSSION: The origins and paths of both the cystic and right hepatic arteries have several documented anomalies. We are unaware of any reports of an RHA that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry. Conclusion: This case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy. Ligation of this uniquely located aberrant RHA could have led to intraoperative hemorrhage or potential hepatic ischemia.     

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma

BackgroundCombined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma.Materials and methodsWe retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction.ResultsOf the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group.ConclusionsCombined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.     

Expanding the applications of microvascular surgical techniques to digestive surgeries: a technical review

In living donor liver transplantation (LDLT), it is considered safer to reconstruct hepatic arteries (HAs) under a microscope than under conventional loupe magnification, because graft HA stumps are generally thin and short with an average diameter of approximately 2 mm. We first applied microvascular surgical techniques to HA reconstruction for LDLT in 1996. In most cases, we use a disposable double-clip to secure the graft and recipient arteries, and interrupted 8-0 nonabsorbable monofilament sutures. We next started performing resection and reconstruction of the right HA in a surgery for hilar cholangioma using the same technique as in LDLT. Lately, we have started applying microvascular surgical techniques to various digestive surgeries; namely, supercharge and superdrainage in esophageal surgery, vascular reconstruction in free jejunal interposition grafts for cervical esophageal cancer, resection and reconstruction of spontaneous HA aneurysms, jejunal artery reconstruction for spontaneous superior mesenteric artery dissections, and so forth. Mastering this technique is time consuming. However, once a surgeon masters the technique it has almost unlimited applications, and most vital vessels can be safely reconstructed using this method. We herein provide a technical review of the application of microvascular surgical techniques for various digestive surgeries.