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Split-liver transplantation has been introduced as an alternative to whole-liver transplantation to increase the donor pool. Because of its anatomy, the liver can be divided into 2 hemilivers suitable for use as 2 grafts for liver transplantation.

The first ever clinical attempt at split-liver transplantation was made in 1988 by Pichlmayr et al,1 followed a year later by a report of 2 fulminant hepatic failure patients each receiving a split graft.2 Reduced-size liver transplantation was initially performed in a child by Bismuth, Houssin, and Broelsch, demonstrating the technical feasibility of the procedure.3

Doyle et al. reported excellent outcomes for both adults and children receiving split-liver grafts.4


  • Donor selection is essential for successful liver splits. Consider healthy donors with a body mass index (BMI) <25 kg/m2, age <35 years old, and minimal comorbidities.5

  • In situ split allows for better identification of potential anatomic variations that would hinder the use of the donor organ as a split liver.5

  • Careful selection process for recipients, considering the recipient size, anatomy, and illness severity.5


In its most commonly used form, the liver can be transplanted into one adult and one child by splitting it into a right extended and a left lateral graft. In another form, 2 hemigrafts are obtained by splitting the liver, which can be transplanted into a medium-sized adult (the right side) and a large child or small adult (the left side).6

For a right lobe graft all common structures (i.e., portal vein, celiac trunk, common bile duct, and inferior vena cava) remain attached to the right lobe grafts. The donor liver was split along the main portal fissure separating the right and the left lobes (Fig. 62-1) when recipients were nearly the same size. The parenchymal transection (Fig. 62-2) should be made in the plane of the falciform ligament for the creation of a left lateral lobe graft (segments 2 and 3) (Fig. 62-3). The left lateral segment graft should include the left hepatic vein (Figs. 62-4 and 62-5) and the left portal vein, left hepatic artery, and left bile duct (Fig. 62-6).


Anterior aspect of a left lobe split-liver graft. White arrows show the parenchymal transection line. A black arrow shows the falciform ligament.


Parenchymal transection. The blue arrow shows the round ligament. The white arrow shows the transection line. Clamp crushing was used to differentiate vascular and biliary structures that must be closed. The blue star shows the left lateral segment graft.


Left lateral segment ...

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