Portal vein reconstruction in liver transplantation from live donor grafts has major challenging factors in cases with portal venous thrombosis (PVT). To overcome this critical surgical challenge, we devised a novel technique, intraoperative ultrasonography (IOUS)-guided thrombectomy of the portal vein. IOUS-guided thrombectomy was applied to the 10 patients whose PVT extended to the splenomesenteric junction. In these patients, closed thin scissors were inserted from the stump of the recipient portal vein under ultrasound guidance and the thrombus was dissected from the venous wall. The application of IOUS-guided thrombectomy in patients with moderate to severe PVT led to a 3-year patency rate of 83%, comparable to that of simple thrombectomy applied to partial or minimal (grade I-II) PVT (83%). IOUS-guided thrombectomy is helpful to adequately remove severe thrombi from the deep lumen of the portal vein, provided the procedure was carried out by an experienced surgeon with adequate preparation for unexpected venous injuries.