Budd-Chiari syndrome is an unusual form of portal hypertension secondary to thrombosis of the hepatic veins. This results in a massively congested liver, which usually presents with massive ascites. The diagnosis is confirmed by an attempt to catheterize the hepatic veins. This generally demonstrates all three to be thrombosed. In the past, liver biopsy was thought to be risky, but more recent evidence demonstrates that it is a safe procedure. It is indicated because, if substantial cen­tral necrosis (as well as bridging fibrosis) is present, the patient is a candidate for a liver transplant. But if only central necrosis is present (with no bridging fibrosis), patients can be treated by mesenteric systemic venous shunting with virtual return to normal anatomy of the liver and normal function. This is generally carried out by performing a mesocaval or a side­to-side portacaval shunt. In some instances with Budd-Chiari syndrome, however, the inferior vena cava is thrombosed. In other instances, the caudate lobe becomes so hypertrophied that the inferior vena cava is compressed to the point of almost being totally obstructed. In both instances, the inferior vena cava is not a suitable receptacle for a mesenteric systemic venous shunt, and a mesoatrial shunt is the shunt of choice. In the past, angiography was performed to demonstrate a patent mesenteric venous system. That is no longer necessary because magnetic resonance angiography or three-dimension­al CT scans can beautifully demonstrate mesenteric venous patency and anatomy. Inferior vena cavography should be per­formed, however, to look for inferior vena cava occlusion, or an inferior vena cava compressed with a high pressure.

phatic channels in the retroperitoneum, and to decrease the amount of ascites formation subsequently, these tissues should be clamped, divided, and ligated. Once the superior mesenteric vein has been identified, a 6 or 7 cm length is mobilized circumferentially (1). Small venous branches are ligated and divided. Large branches are controlled by double looping with vessel loops. Once a long length of superi­or mesenteric vein has been cleaned up to the inferior border of the neck of the pancreas, the root of the transverse meso­colon is divided and the lesser sac entered. This requires exposing a short length of the inferior border of the pancreas. It also requires dividing sizable arterial branches, occasionally including the middle colic artery, coursing anteriorly from the supe­rior mesenteric artery. If an artery is so large that one is concerned with viability of the colon, the artery should be occlud­ed with a bulldog clamp temporarily to be certain that a good pulse remains in the marginal artery.