American Journal of Transplantation 2003; 3: 1323–1335
C Blackwell Munksgaard 2003
Blackwell Munksgaard
Minireview
Split-Liver Transplantation: A Review
John F. Renza, ∗ , Hasan Yersizb ,
Paulo R. Reichertc , Garrett M. Hisatakeb ,
Douglas G. Farmerb , Jean C. Emonda
and Ronald W. Busuttilb
a equaled or exceeded cadaver whole-organs in children (6–
Center for Liver Disease and Transplantation, College of
Physicians and Surgeons of Columbia University,
New York Presbyterian Hospital, New York, NY
b
Dumont-UCLA Transplant Center, University of California
Los Angeles, Room CHS 77-120, 10833 Le Conte
Avenue, Los Angeles, CA
c
Department of Anatomy, Universidade de Passo Fundo,
Passo Fundo, Brazil
∗Corresponding author: John F. Renz,
jfr2103@columbia.edu
Split-liver transplantation (SLT), a procedure where
one cadaver liver is divided to provide for two re-
cipients, offers immediate expansion of the existing
cadaver donor pool. To date, the principal beneficia-
ries of SLT have been adult/pediatric recipient pairs
with excellent outcomes reported; however, the cur-
rent scarcity of cadaver organs has renewed interest
in expanding these techniques to include two adult
recipients from one adult cadaver donor. Significant
obstacles to the widespread application of SLT exist
and must be resolved by the transplant community be-
fore greater utilization can be realized. This manuscript
reviews the historic background, surgical techniques,
current results, and obstacles impeding further appli-
cation of SLT.
Key words: Hepatobiliary surgery, liver transplan-
tation, organ donation, partial-organ liver trans-
plantation, pediatric liver transplantation, split-liver
transplantation
Received 4 February 2003, revised 10 June 2003 and
accepted for publication 24 June 2003
Historic Background
Transplantation of partial-liver allografts was initially advo-
cated by Smith, who proposed the left lateral segment
as suitable for children in 1969 (1). Smith’s proposal re-
mained untested until the 1980s, when increasing demand
for pediatric, cadaver organs resulted in prolonged wait-
ing times and increased wait-list mortality (2,3). Initial at-
tempts to create pediatric partial-liver allografts focused
upon the surgical reduction of a larger child or adult cadaver
Copyright 
ISSN 1600-6135
doi: 10.1046/j.1600-6135.2003.00254.x
organ to fit the abdominal cavity of the recipient, termed
reduced-liver transplantation (RLT), which was simulta-
neously reported by Bismuth (4) and Broelsch (5) in
1984. Early efforts were plagued by technical difficulties;
however, later series demonstrated RLT graft outcomes
8). While improved outcomes had been achieved in the
treatment of children, the discard of a right hemi-liver and
the increased competition created between adult and pe-
diatric candidates for the same donor pool rendered the
procedure impractical (2,9,10).
To expand the donor pool, the surgical techniques of RLT
were modified to create a pediatric left lateral segment
graft with a remnant graft suitable for transplantation of an
adult. These techniques could be applied to cadaver donors
in the performance of SLT (11,12) or to live volunteers to
create living-donor liver transplantation (13,14).
Pichlmayr (11) and Bismuth (12) each reported success-
ful split-liver transplantation in 1989. Emond from the Uni-
versity of Chicago reported an initial series of nine SLT
procedures in 18 adult and pediatric recipients in 1990
(15). Overall patient and graft survival were lower than
whole-organ recipients with a higher incidence of com-
plications and need for re-transplantation (15). While the
outcomes were inferior to cadaver whole-liver transplan-
tation, the early data were promising, leading the authors
to conclude ‘[SLT] is feasible and could substantially im-
pact transplant practice’ (15). Interest in SLT precipitously
declined when an expanded University of Chicago se-
ries failed to demonstrate improved SLT outcomes vs. ca-
daver whole-organs or partial-organ allografts from living
donors (16).
Select European centers pursued SLT with de Ville de
Goyet reporting data on 100 grafts from the European
Split Liver Registry in 1995 (17). Recipient and graft sur-
vival correlated to medical acuity at transplantation with
elective pediatric recipient and graft survival of 89% and
80%, respectively. In the setting of urgent medical acuity,
recipient and graft 6-month survival were only 61%. Elec-
tive adult recipient and graft survival were 80% and 72%,
vs. 67% and 55%, respectively, for adults requiring urgent
transplantation. Twenty percent of grafts were lost to com-
plications including hepatic artery thrombosis (11%), por-
tal vein thrombosis (4%), and a 19% incidence of biliary
complications (17). These data were significantly improved
from previous SLT series and equivalent to European Liver
Transplant Registry survival data for cadaver whole-organs.
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Renz et al.
Pichlmayr (11) and Bismuth (12) advocated SLT as an
ex vivo procedure performed at the recipient institution
following a standard, cadaver whole-organ procurement.
This technique preserves routine procurements at the
donor institution with the allocation of specialized skills and
prolonged operating room time to the recipient institution.
However, ex vivo dissection lengthens cold ischemia time
and potentially exposes the graft to re-warming through
manipulation. Broelsch (18) and Busuttil (19) introduced a
technical modification by performing the split-technique in
situ at the donor hospital with surgical division completed in
the heart-beating cadaver immediately prior to aortic cross
clamp and organ cold perfusion.
In situ SLT requires specialized skills and prolonged operat-
ing room time at the donor institution. Increased logistics
coordination is necessary, but SLT can routinely be per-
formed without special equipment or impedance of tho-
racic or additional abdominal organ procurements (20,21).
In situ separation reduces cold ischemia, simplifies identifi-
cation of biliary and vascular structures (18,22), eliminates
unintentional graft rewarming during ex vivo manipulation,
and reduces hemorrhage upon graft reperfusion (22,23).
Preliminary in situ SLT data from the University of Hamburg
in 1996 (24) and the University of California Los Angeles
(UCLA) in 1997 (19) yielded pediatric as well as adult re-
cipient graft and patient survival that equaled or exceeded
whole cadaver-organ data.
Since their initial reports, both UCLA (25) and the Uni-
versity of Hamburg (26) have published expanded se-
ries confirming previous outcomes. UCLA has the largest
in situ SLT experience with more than 100 procedures per-
formed and has adopted the in situ technique as routine
when an optimal donor is available (27). With this com-
mitment, SLT accounts for approximately 10% of adult
and 40% of pediatric grafts at UCLA (27), but only 2% of
all transplants performed nationally over the past decade
(28). Split-liver transplantation and living donation are com-
plementary, not competitive, strategies for expansion of
the donor pool; however, as SLT preserves the benefits of
pediatric living-donor liver transplantation without incurring
donor risk (20,27,29), it is the authors’ procedure of choice.
Surgical Techniques
Donor selection
Paramount to the success of SLT is donor and recipient se-
lection. We (27) and others (22,30) have restricted donor
selection to optimal candidates with respect to age, ABO
compatibility, size-match, liver function, vasopressor re-
quirements, absent/scant arrest period, brief donor hospi-
talization, and serum sodium concentration. These donor
criteria have not been assessed prospectively and may be
unnecessarily conservative; however, SLT involves an ele-
ment of risk and the consequences of primary nonfunction
in two patients at the same time are devastating. Accu-
rate donor assessment from the recovery team is equally
1324
important. Potential grafts must be assessed for size, vas-
cular and biliary anatomy, as well as parenchyma quality
and quantity.
Split-liver transplantation requires extended dissection ei-
ther within the heart-beating donor or on the back table
ex vivo. The increased blood loss and volume replacement
incurred during in situ SLT has prompted concerns that the
quality of thoracic organs may be affected (31). Data from
our center on 100 consecutive in situ procedures and oth-
ers with a commitment to in situ SLT suggest the effect on
additional abdominal and thoracic organs is negligible (21)
(27). We allocate 90 min of additional operating room time
for an adult/pediatric in situ SLT and 3 h for an adult/adult
in situ SLT. While longer procurement times have been re-
ported (30), in situ SLT has not been an excessive temporal
burden in our experience, provided adequate communica-
tion has occurred between all procurement teams (27). We
routinely advise the organ procurement agency of a poten-
tial in situ SLT at the time of offer so other procurement
teams can adjust their arrival schedules. Unfortunately, no
data exists on the additional costs incurred by the perfor-
mance of in situ SLT.
Anatomic principles
Any technical description must begin with the anatomic
classification system of Couinaud (32) refined by Bismuth
(33) (Figure 1), which has been universally accepted by the
transplant communities of Europe, Asia, and North Amer-
ica as the reference for describing partial-organ allografts.
The liver is divided into eight functional units, termed ‘seg-
ments’, that receive separate hilar pedicles: each contain-
ing a portal venous branch, hepatic arterial branch, and a
Figure 1: Segmental liver anatomy. The segmental anatomy of
the liver as described by Couinaud (32) and Bismuth (33). Each
anatomic segment (roman numeral) receives a unique portal pedi-
cle (light blue) consisting of a portal venous branch, hepatic arterial
inflow, and bile duct. Individual segments are drained by unique
hepatic venous outflow branches (dark blue) and separated by
connective tissue scissurae. Reprinted from Liver Transplantation,
Vol. 7(12); 2001: 1077–1080, with permission from the American
Association for the Study of Liver Diseases.
American Journal of Transplantation 2003; 3: 1323–1335

Figure 2: Surgical division of the liver. Surgical division of the
liver along the middle hepatic vein (yellow line labeled ‘A’) yields
a left lobe (segments I–IV) and right lobe (segments V–VIII) graft
that can be utilized in SLT between two adults. Division along the
falciform ligament (white line labeled ‘B’) yields the pediatric left
lateral segment graft (segments II–III) and the remnant, adult right
trisegment graft (segments I, IV–VIII).
bile duct radicle with unique drainage through individual
venous branches. Hepatic parenchyma transection corre-
sponds to ‘scissurae’ or connective tissue planes that sep-
arate individual liver segments, thereby reducing intraoper-
ative blood loss and postresection parenchyma ischemia.
Couinaud’s classification permits the creation of function-
ally distinct partial-organ allografts (Figure 2). Division of
the hepatic parenchyma at the falciform ligament yields
a segment II/III graft, termed a left lateral segment graft,
of approximately 250cc in volume for pediatric recipients
(27) (34), and a remnant Couinaud segment I, IV–VIII ‘right
trisegment’ graft of approximately 1100cc for transplanta-
tion of adults (27). The left lateral segment graft can be
further reduced to a ‘monosegment graft’ (segment III) for
very small infants and neonates (Figure 3; 35).
For transplantation of two larger individuals from one adult
cadaver donor, the liver can be divided along the mid-
dle hepatic vein to create two nearly equal-sized grafts
(Figure 2). Left lobe grafts of approximately 400cc in vol-
ume can be created with (segments I–IV) or without the
caudate lobe (segments II–IV) for recipients with typically
less than 60 kg of body mass. Right lobe grafts (segments
I, V–VIII, or V–VIII) have a typical volume of approximately
800–1000cc and are generally suitable for candidates
≤80 kg (36–39).
Creation of left lateral segment II, III and right
trisegment I, IV–VIII grafts
Prior to the performance of any split procedure, the stan-
dard techniques of abdominal organ procurement, includ-
ing supra-celiac and infra-renal aortic dissection as well as
cannulation of the inferior mesenteric vein, should be com-
American Journal of Transplantation 2003; 3: 1323–1335
Split-Liver Transplantation
Figure 3: Pediatric monosegment graft. The pediatric
monosegment graft (segment III) is created by the surgical
reduction of a left lateral segment graft (segments II/III) and
is applicable to very small infants and neonates (35). The
top-left plane of transection is the remnant falciform liga-
ment while the middle-right transection plane is removal of
segment II.
pleted to insure that if a donor were to become unstable,
the SLT could be aborted with rapid progression to aortic
cannulation, cross-clamp, and organ cold perfusion (40).
Split-liver transplantation is initiated with division of the fal-
ciform ligament to expose the hepatic vein-caval junction.
The left hepatic vein is isolated and encircled with a ves-
sel loop. Occasionally, the division of the middle and left
hepatic veins will not be distinguishable or segments II and
III will have independent orifices to the cava (41). A com-
mon middle and left hepatic vein requires separation after
parenchyma division. Recognition of independent segment
II and III veins is critical to avoid inadvertent injury and re-
quires that both orifices are incorporated on a common
caval patch (41).
Hilar dissection begins at the base of the round ligament
with isolation of the left hepatic artery, left portal vein
branch, and left bile duct branch. The left hepatic artery
is encircled and dissection is continued along its entire
length. Particular attention is devoted to the preservation
of segment IV penetrating arteries (41,42) (Figure 4). If the
segment IV branch arises high off the left hepatic artery and
provides significant inflow, our practice is to anastomose
the segment IV artery to the right trisegment graft’s gastro-
duodenal remnant. Portal venous branches to segment IV
are ligated and divided lateral to the umbilical fissure to
isolate the entire left portal vein.
With vascular control of the left lateral segment achieved,
parenchyma transection is initiated with electrocautery by
scoring the liver surface approximately 1 cm to the right
of the falciform ligament (41). The parenchyma is divided
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Renz et al.
Figure 4: Left hepatic artery servicing segment IV. Large
branch from the left hepatic artery servicing segment IV.
between the left lateral segment and segment IV and car-
ried to 1 cm above the left bile duct in the umbilical fissure
(42). Small penetrating vessels and biliary radicles are su-
ture ligated as required. The left hilar plate, containing the
bile duct, is sharply transected. This separates the left lat-
eral segment from the remaining parenchyma with its own
vascular pedicle and venous drainage. Following cold per-
fusion, the left hepatic artery, the left portal vein, and the
left hepatic vein are sharply divided and the left bile duct
flushed with cold University of Wisconsin (UW) solution®
(Viaspan, Pomona, NY) prior to storage (Figure 5). The right
trisegment graft is removed in the standard fashion and
stored at 4 ◦ C in UW solution (40).
Transplantation of the left lateral segment graft requires
preservation of recipient inferior vena cava. The right hep-
Figure 5: Left lateral segment graft. Left lateral segment graft
after completion of split-liver transplantation. The remnant left hep-
atic artery (HA), portal vein (PV) and bile duct (BD) are labeled. The
mass of the pictured specimen was 250 g.
1326
atic vein orifice to the vena cava is suture ligated, as are
the smaller accessory hepatic veins along the inferior vena
cava. The left and middle hepatic vein orifices are opened
to form a large common trunk for hepatic venous anasto-
mosis (43). All anastomoses are performed with surgical
telescopes of between ×2.5 and 4.5. Anastomosis of the
portal vein is performed end-to-end utilizing nonabsorbable
monofilament suture. For infants and neonates, the anasto-
mosis is run on the posterior wall and interrupted anteriorly.
The donor hepatic artery is anastomosed to the recipient
common hepatic artery or to the infrarenal aorta by a ca-
daver artery interposition graft utilizing interrupted ≥7–0
nonabsorbable monofilament suture. Biliary anastomoses
are occasionally performed duct-to-duct, but more fre-
quently are performed by end-to-side hepato-jejunostomy
using a single-layer, interrupted 6-O absorbable suture with
an internal stent.
Preparation of the right trisegment graft for transplantation
includes removal of remnant diaphragm from the liver bare
area, ligature of phrenic vein origins, closure of the left hep-
atic vein, left portal vein, and left hepatic artery orgins with
possible re-vascularization of a segment IV arterial branch,
and oversew of the left bile duct remnant. The parenchyma
surface is carefully inspected during back-table preparation
for possible vascular and biliary leaks that are oversewn.
Gently flushing each structure aids in the identification.
The graft is now ready for transplantation, utilizing stan-
dard whole-organ techniques (40).
Creation of left segment II, III, IV and right segment I,
V–VIII grafts
Grafting of left lobe segments II–IV is applicable to toddlers,
teenagers, and adults less than 60 kg in weight (37). The
dissection proceeds in a similar fashion as above to iden-
tify the hepatic vein origins. In this technique, the middle
and left hepatic veins are together encircled with a vessel
loop to guide parenchyma dissection. The left bile duct,
left hepatic artery, and left portal vein (42,44) are identified
with dissection carried distal along the entire extra-hepatic
length to the level of the round ligament. Left hepatic artery
branches servicing segment IV are preserved (Figure 4).
The left portal vein is freed along its entire length with di-
vision of all caudate lobe branches.
Occlusion of the left portal vein and left hepatic artery gen-
erates a demarcation plane for parenchyma transection.
The plane is marked by electrocautery and proceeds to the
hilar plate, ligating parenchyma vessels as encountered.
At the hilar plate, the left bile duct is sharply transected.
The left hepatic artery and left portal vein are preserved for
organ cold perfusion. Heparin is administered followed by
aortic cannulation, cross-clamp, and organ cold perfusion.
Split-liver transplantation continues with sharp transection
of the left portal vein just distal to the bifurcation and tran-
section of the right hepatic artery just distal to its takeoff
from the proper hepatic artery. The common portal vein
American Journal of Transplantation 2003; 3: 1323–1335

Figure 6: Arterial supply of segment IV from the right hepatic
artery. The hepatic corrosion casts depict >1-mm branches of
the right hepatic artery crossing Cantlie’s line to supply segment
IV. (A) Right hepatic artery (RHA) branch to segment IV (crossing
branch) is superior and posterior to the portal bifurcation (PV: portal
vein, LPV: left portal vein, RPV: right portal vein, LHA: left hepatic
artery, PHA: proper hepatic artery). (B) Right hepatic arterial branch
to segment IV (crossing branch) is anterior to the left portal vein.
Reprinted from Liver Transplantation, Vol. 7(12); 2001: 1077–1080,
with permission from the American Association for the Study of
Liver Diseases.
and common hepatic duct are maintained with the right
graft while preserving the celiac axis with the left graft.
The authors’ preserve the celiac axis with the left graft
to maximize arterial supply to segment IV, which is rou-
tinely derived from branches of the left and right hepatic
arteries (37,41,44) (Figure 6). The left and middle hepatic
veins are taken from the suprahepatic vena cava as a com-
mon cuff and the left bile duct is flushed with UW solution
prior to cold storage (Figure 7). Ex vivo graft preparation
only requires identification and repair of cut-surface biliary
radicles.
The segment I, V–VIII graft is procured by standard organ
recovery techniques followed by irrigation of the common
bile duct and storage in cold UW solution (40). Ex vivo
preparation of the segment I, V–VIII graft may require vas-
cular reconstruction with donor-derived conduit vessels.
American Journal of Transplantation 2003; 3: 1323–1335
Split-Liver Transplantation
Figure 7: Left lobe segment II, III, and IV graft. Left lobe graft
after completion of split-liver procedure. Anatomic segments are
labeled for orientation. Note preservation of the entire celiac trunk
with the left lobe graft to minimize potential ischemia of segment
IV. The mass of the pictured specimen was 480 g. Reprinted from
Liver Transplantation, Vol. 8(1); 2002: 78–81, with permission from
the American Association for the Study of Liver Disease.
Recognition of the significance of middle hepatic venous
branches in the drainage of segments V and VIII (45–47)
(Figure 8) have lead our team to include these branches
in vena cava anastomoses, which may require vascular
conduit.
Creation of left segment I–IV and
right segment V–VIII grafts
Left lobe grafts (segments I–IV) that include the caudate
lobe may be used for adults weighing as much as 65 kg
and, in select circumstances, heavier individuals (38,39).
Segment V–VIII grafts generally permit size-for-size donor
to recipient weight ratios or even slightly smaller donors to
donate to larger recipients. As described earlier, the hepatic
veins are identified and the right hepatic vein is encircled
with a vessel loop. The diaphragmatic attachments to the
liver are released with the dissection continued on the right
lobe to the inferior vena cava. The left border of the inferior
vena cava is not disturbed. Accessory hepatic veins are en-
countered in approximately 15% of cadaver donors and are
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Renz et al.
Figure 8: Middle hepatic vein (MHV) draining segments V and
VIII. (A) Corrosion cast demonstrating a dominant MHV which
sweeps laterally to drain segments V and VIII. Three large commu-
nicating branches (lettered A, B, C) create a collateral flow within
segments V and VIII between the middle and right hepatic vein
(RHV). (B) This anatomic variant is further depicted during intraop-
erative ultrasound. Reprinted from Liver Transplantation, Vol. 6(3);
2000: 367–369, with permission from the American Association
for the Study of Liver Diseases.
individually preserved with a caval patch for implantation if
larger than 5 mm in diameter.
Following retrograde cholecystectomy, the hepato-
duodenal ligament is opened to expose the hilum. The
right hepatic artery is identified and exposed lateral to the
common hepatic duct. Of note, the right hepatic artery
is rarely anterior to the common hepatic duct except in
the circumstance of replaced arterial anatomy. Lateral
exposure avoids skeletonization of the proper hepatic
bifurcation thereby preserving arterial supply to segment
IV from the right hepatic artery (Figure 6). The right portal
vein is approached from the right side of the hilum (lateral)
and dissected to the level of the bifurcation where it is
encircled with a vessel loop (Figure 9). A Pringle maneuver
of the left hilum is performed to create a demarcation
line for parenchyma division. The left bile duct is sharply
divided at the hilar plate and bleeding points secured with
1328
Figure 9: Hilar dissection. The right portal vein is dissected and
encircled with a vessel loop. The cystic duct is retracted by the
forceps and the right hepatic artery (RHA) lies above the common
hepatic duct. This is an anatomic variant. The location of the right
hepatic artery anterior to the common hepatic duct is rare except
in the setting of replaced arterial anatomy (main portal vein: PV,
common bile duct: CBD). Reprinted from Liver Transplantation,
Vol. 8(1); 2002: 78–81, with permission from the American Asso-
ciation for the Study of Liver Diseases.
6 : 0 nonabsorbable monofilament suture. Parenchyma
division is performed along the main portal fissure with
the surgeon’s left fingertips positioned behind the right
lobe anterior to the inferior vena cava. Segment V and VIII
venous tributaries are sharply divided for later revascu-
larization. Upon completion of parenchyma division, the
right hepatic vein, right portal vein, and right hepatic artery
are maintained for organ cold perfusion (Figure 10). Graft
separation includes sharp division of the right portal vein
just distal to the bifurcation and transection of the right
hepatic artery just distal to its takeoff from the proper
hepatic artery. The right hepatic vein is divided from the
suprahepatic vena cava as a patch and the right segment
V–VIII graft is removed. The bile duct is flushed prior to
cold storage in UW solution. Ex vivo preparation of the
segment V–VIII graft includes suture ligature of small
biliary radicles and potential restoration of segment V and
VIII venous outflow (Figure 8).
The left segment I–IV graft is removed, utilizing standard or-
gan recovery techniques followed by irrigation of the com-
mon bile duct and storage in cold UW solution (40). Ex vivo
preparation includes closure of the right portal vein orifice,
right hepatic vein orifice, and right hepatic artery orifice, as
well as suture ligation of parenchymal biliary radicles.
Right lobe segment V–VIII grafts require the recipient’s
inferior vena cava (40). The graft is positioned orthotopi-
cally with a graft hepatic vein to recipient right hepatic
vein orifice anastomosis or to a common trunk formed
by the recipient’s remnant left, middle, and right hep-
atic vein orifices (30,38). Middle hepatic venous branches
American Journal of Transplantation 2003; 3: 1323–1335

Figure 10: Completion of parenchymal transection. The
parenchymal dissection has been completed and the grafts are
ready for cold perfusion. The left bile duct has been separated;
however, the hepatic arterial (left hepatic artery encircled by red
vessel loop) and portal venous systems are intact.
draining segments V and VIII (45–47) (Figure 8) as
well as accessory hepatic veins ≥5 mm in diameter
are included in anastomoses either directly to the vena
cava or through utilization of venous conduit. End-to-end
anastomosis of the portal vein is frequently possible, as
is the right hepatic artery to a suitable inflow source from
the common hepatic artery. Donor iliac artery or vein may
be used for interposition grafting. Biliary drainage may be
achieved through end-to-end anastomosis or Roux-en-Y
hepaticojejunostomy.
Technical considerations
All techniques described require only standard surgical fa-
cilities with no specialized equipment and have been per-
formed concomitant with additional abdominal and thoracic
organ procurements. Surgical anatomy is defined during
the donor procedure, particularly if parenchyma division is
performed in situ, as preoperative liver imaging is not prac-
tical in most donor hospitals. In ex vivo SLT, dissection may
be augmented by cholangiography as well as angiography.
Successful SLT requires recognition that partial-liver
grafts predispose to unique complications resulting from
American Journal of Transplantation 2003; 3: 1323–1335
Split-Liver Transplantation
anatomic variations as well as recipient physiology. Techni-
cal challenges include the creation of sufficient liver volume
to meet the metabolic demands of the recipient, graft po-
sitioning to optimize vascular flow and biliary drainage, as
well as an appreciation of anatomic variations that necessi-
tates complex biliary or vascular reconstruction. Frequent
complications among SLT recipients include parenchyma
bile leak, hepatic arterial thrombosis, hepatic venous out-
flow obstruction, infection from remnant necrotic tissue,
and poor graft function secondary to insufficient hepatic
volume. Graft mass is a critical variable affecting outcomes
and a limitation in the extension of SLT between two
adults. Adequate graft mass has been extensively explored
in living donor liver transplantation with minimal graft
thresholds advocated (48–52); however, these data are
not directly applicable to SLT as parenchyma quality, and
immediate function of living donor grafts exceeds that of
cadavers (27,53,54). Our preference is a graft mass of
at least 1% recipient body weight; however, grafts less
than 0.8% recipient body weight have been utilized with
success (30,55,56).
Inadequate graft mass for the recipient manifests as
a pattern of dysfunction associated with portal hyper-
perfusion, prolonged cholestasis and gradual recovery,
termed ‘small-for-size syndrome’ (48,55). ‘Small-for-size
syndrome’ is characterized by synthetic dysfunction, a mild
trans-aminitis (×2–4 upper limit of normal), and prolonged
cholestasis. Improved synthetic function typically occurs
within 72 h of reperfusion as the graft undergoes rapid hy-
pertrophy. Cholestasis improves gradually over a course of
weeks. Stable synthetic function signals a reversible sit-
uation that will improve as the graft undergoes regener-
ation; however, the appearance of, or inability to, reverse
encephalopathy, hypoglycemia, metabolic acidosis, or aug-
mentation of synthetic function beyond 48 h heralds irre-
versible graft failure that should prompt re-transplantation.
Graft biopsy reveals a pattern of diffuse ischemic in-
jury demonstrating hepatocyte ballooning, steatosis, cen-
trilobular necrosis, and parenchymal cholestasis that may
be misinterpreted as preservation injury (48). Pathologic
changes frequently subside within 2 weeks of transplan-
tation, except for the presence of cholestasis that may
persist for weeks. While radiologic data demonstrate the
majority of volume regeneration occurring within 7 days af-
ter living-donor liver transplantation (57,58), small-for-size
grafts should be considered highly vulnerable during the
immediate postoperative period to insult with an increased
risk of developing sequelae from complications or addi-
tional metabolic stress.
Current Results
The absence of a dedicated SLT registry has limited data
to individual center reports. An abstract from the Joint
Meeting of the International Liver Transplantation Society,
European Liver Transplantation Association, and the Liver
Intensive Care Group of Europe in 2001 suggested that
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Renz et al.

split procedures represented 3.7% of the total grafts
from the European Liver Transplant Registry between May
1968 and June 2000 (59); however, outcomes were not
reported. The American Society of Transplant Surgeons
(ASTS) has recently performed a survey of 89 North Amer-
ican transplant centers participating in the United Network
for Organ Sharing (UNOS) Scientific Registry for Transplant
Recipients (SRTR) on the utilization of SLT (28,60). This re-
view summarizes outcomes from the ASTS survey, indi-
vidual center reports, and SLT data from the SRTR.
The ASTS survey, performed between 04/00 and 05/01,
elicited a response from 83 of 89 surgical teams identi-
fied from the Annual Report of the SRTR (61) as having
performed at least one liver transplant procedure during
the previous year. Thirty-six of the responding teams re-
ported data on 207 left lateral segment, 152 right triseg-
ment, 15 left lobe, and 13 right lobe grafts (60). Split-liver
transplantation was most frequent in the setting of at least
one urgent recipient with the majority of each graft type
applied to UNOS status I and IIA recipients. Five groups
reported sharing 18 grafts over a distance of <10 miles
to across the United States. Experience was concentrated
among 13 groups reporting five or more SLT procedures
that accounted for 221 grafts or 57% of the cumulative
data. The majority of groups reporting experience with SLT
(63%) had performed less than five procedures. Cadaver
whole-liver transplantation volume correlated with the ap-
plication of SLT (60).
Complications were frequent in all graft types with biliary
and vascular complications equally distributed between
grafts split by either ex vivo or in situ techniques. Pri-
mary nonfunction, graft failure, and recipient death corre-
lated with recipient UNOS status at transplantation (60).
The overall incidence of complications among left lat-
eral segment recipients was 32% and relatively uniform
across UNOS recipient status. However, the relative con-
tribution of the complication type varied, with vascular
complications being more frequent in critically ill recipi-
ents and biliary complications being more common among
nonurgent recipients. Primary nonfunction and graft fail-
ure occurred principally in UNOS status I recipients. Re-
cipient mortality was 4-fold more frequent in UNOS sta-
tus I recipients with two-thirds attributed to graft-related
complications (60).
While the majority of right trisegment grafts were uti-
lized in nonurgent recipients, morbidity and mortality were
concentrated among urgent, UNOS status I and IIA SLT
recipients. The overall incidence of right trisegment graft
complications was 26%, with biliary complications be-
ing most frequent, followed by vascular complications,
and post-transplant hemorrhage. Hepatic artery thrombo-
sis was the most frequently reported vascular complication
with five reported cases of hepatic artery pseudoaneurysm
and one hepatic artery disruption. There was a 4% inci-
dence of primary nonfunction and a 15% incidence of mor-
tality with more than one-half of deaths being attributed to
graft-related complications (60).
Single-center outcomes for the performance of
adult/pediatric SLT are summarized in Table 1. The
32% incidence of left lateral segment graft complications
reported by the ASTS survey is similar to data from
individual centers, as is the classification of complications,

Table 1: Adult/pediatric split-liver transplantation

Center Author Year n Recipient Graft Comp
Left lateral segment graft data
Los Angeles (27) Yersiz 2003 92 78% 68% 24%
Hamburg (29) Broering 2001 49 82% 76% 28%
Birmingham (62) Noujaim 2001 49 N/A N/A >8%
Berlin (76) Sauer 2001 18 93% 87% 44%
Milano (77) Maggi 2001 11 89% 66% 23%
Houston (63) Kilic 2001 8 100% 100% 25%
Los Angeles (25) Ghobrial 2000 55 76% N/A N/A
London (70) Rela 1998 22 86% 82% 45%
Los Angeles (19) Goss 1997 12 100% 80% 25%
Hamburg (18) Rogiers 1996 7 86% 71% 57%
Right trisegment graft data
Los Angeles (27) Yersiz 2003 71 79% 69% 34%
Hannover (69) Nashan 2001 78 80% N/A N/A
Hamburg (29) Broering 2001 49 N/A N/A N/A
Birmingham (62) Noujaim 2001 37 N/A N/A >15%
Berlin (76) Sauer 2001 18 90% 90% 39%
Milano (77) Maggi 2001 16 86% 80% 12%
Houston (63) Kilic 2001 8 100% 100% 12%
Los Angeles (25) Ghobrial 2000 55 80% N/A N/A
London (70) Rela 1998 22 95% 95% 27%
Los Angeles (19) Goss 1997 14 86% 93% 19%
Hamburg (18) Rogiers 1996 7 100% 100% 28%
n = graft number, recipient = recipient survival, graft = graft survival, comp = reported overall complication rate, N/A = data not reported.

1330 American Journal of Transplantation 2003; 3: 1323–1335

 Split-Liver Transplantation

with biliary complications being most common (29),
followed by a 5–9% incidence of vascular complications
(29,62,63). Right trisegment graft data were also similar
between the ASTS survey and the single-center reports
with respect to the incidence and nature of complications
(Table 1). All studies identify poor outcomes in the setting
of urgent SLT (27).
1-year, particularly among left-SLT recipients. The authors
performed SLT in 15% of available donors and reported a
62% net increase in adult recipients through the routine
application of SLT. They concluded that SLT between two
adults can yield good outcomes; provided recognition of
donor and recipient limitations as well as surveillance for
complications unique to the procedure (56).

Sparse data exist on SLT between two adults, as these The University of Minnesota has reported the largest North
techniques have been cautiously implemented among se- American center data on adult/adult SLT. In 2001, Humar
lect transplant centers. Left and right lobe graft data from reported on 12 SLT grafts with patient and graft survival of
the ASTS survey do not permit meaningful analysis. The 83% at a mean follow up of 9 months (30). Right lobe graft
reported overall incidence of left lobe complications was mean recipient weight was 89 kg vs. a mean weight of
26% vs. 22% for right lobe grafts, with the majority uti- 60 kg for left lobe recipients. Ten of the 12 recipients, all of
lized for urgent recipients (60). Biliary complications were whom were nonurgent status at SLT, were alive and well. A
most frequent with vascular complications reported in 4% later abstract by the same group reported nine procedures
of left lobe vs. 9% of right lobe grafts. Primary nonfunc- yielding 18 grafts with a mean follow up of 18 months
tion and graft failure were 7% and 9% for left lobe vs. 9% (65). Seventeen of the 18 recipients were UNOS status IIB
and 14% for right lobe grafts, respectively. Recipient death and one was UNOS status IIA. Patient and graft survival
was observed in 7% of left vs. 8% of right lobe grafts. were 89% for right lobe vs. 78% for left lobe grafts. Bil-
iary complications were most frequent (27%), followed by
Individual center data on adult/adult SLT are summarized in an 11% incidence of vascular complications that resulted
Table 2. The Paul Brousse group has reported the largest in two deaths. There was one primary nonfunction in an
series on adult/adult SLT (22,56,64). In 1996, Bismuth re- unspecified graft.
ported 1-year patient and graft survival of 79% and 78%,
respectively, on 27 SLT grafts, with the routine appli- Split-liver transplantation has been performed in Asia with
cation of ex vivo SLT increasing overall graft availability organ sharing among countries (66,67). The total number
at their center by 28% (22). The incidence of biliary compli- of SLT procedures is low secondary to scarce cadaver
cations was 22% with a 15% incidence of arterial complica- donation, logistic, cultural, and manpower constraints;
tions and one reported primary nonfunction. A later series however, de Ville de Goyet has reported data on 26 grafts
comparing 1- and 2-year SLT patient and graft survival to obtained by five Asian centers. Complications were not
adults receiving cadaver whole-organ transplantation over stratified by graft type but included parenchyma bile leak,
the same time period demonstrated right- and left-SLT graft portal vein thrombosis, portal vein stenosis, hepatic artery
1-year recipient survival of 74% vs. 88%, respectively, with insufficiency, and T-tube dislodgement requiring celiotomy.
1-year graft survival of 74% for right-SLT vs. 75% for left- Four deaths were reported, yielding an 85% overall recipi-
SLT recipients (56). Graft complications were not uniformly ent survival with at least one additional recipient requiring
distributed with a significantly higher incidence of biliary re-transplantation (67).
complications observed in left grafts and a higher incidence
of arterial complications reported in right grafts (56). While The above data (Table 2) are in general agreement with
no significant difference between whole-organ and SLT re- the ASTS survey data. Similar patterns of complications
cipient 1-year survival was identified, the increased inci- emerged from the ASTS survey data and the Paris group,
dence of complications observed in SLT grafts contributed with vascular complications being more frequent in right
to a significantly decreased incidence of graft survival at lobe grafts and biliary complications more frequent in left
lobe grafts (56). Graft survival is higher in right lobe SLT
recipients with a similar incidence of primary nonfunction
Table 2: Adult/adult split-liver transplantation and recipient death in each group (60).
Center Author Year n Recipient Graft Comp
Preliminary data from the UNOS SRTR has also become
Minneapolis (65) Humar 2001 18 89% 89% 43%
available on SLT. A data request from the Organ Procure-
Villejuif (56) Azoulay 2001 34 81% 75% 24%
Minneapolis (30) Humar 2001 12 83% 83% 58% ment and Transplant Network Liver and Intestinal Trans-
Hamburg (26) Broering 2001 12 93% 85% N/A plantation Committee (68) was submitted to provide out-
Genoa (78) Andorno 2001 10 100% 80% N/A comes of SLT right lobe grafts in adults. As graft-specific
Bergamo (79) Colledan 2000 8 87% 63% 75% coding does not exist in the database, a data search was
Eppendorf (80) Gundlach 2000 4 100% 100% N/A performed for grafts classified as ‘partial right liver seg-
Villejuif (22) Azoulay 1996 27 79% 78% 37% ments’ that had corresponding left segments also trans-
n = graft number, recipient = recipient survival, graft = graft planted or right ‘split liver segments’ prepared either ex
survival, comp = reported overall complication rate, N/A = data vivo or in situ. Assuming SLT is restricted to optimal
not reported. donors, partial right graft outcomes were compared with

American Journal of Transplantation 2003; 3: 1323–1335 1331

Renz et al.
two groups: a comparable group of whole-organ cadaver
donors between 18 and 40 years of age, and a surro-
gate ‘marginal donor’ group consisting of cadaver whole-
organ donors greater than 60 years of age. Between 1994
and 2001, 215 SLT right grafts were identified. These in-
cluded 33 partial, 42 in situ, and 140 ex vivo grafts that
were compared with 2901 grafts procured in donors >60
years old and 9802 grafts procured from donors aged 18–
40 years (68). Outcomes, measured by graft failure and
recipient death were stratified by medical urgency sta-
tus and adjusted for body mass index, year of transplant,
cause of death, ABO blood compatibility, history of pre-
vious liver transplant, indication for transplantation, cold
ischemic time, creatinine >2 mg/dL, medical condition,
and donor/recipient age, gender, and ethnicity. Graft failure
and death occurred in 32% and 26% of right SLT recip-
ients, respectively, with outcomes comparable to whole-
organ grafts from donors >60 years of age, and inferior
to outcomes from cadaver whole-organ donors aged 18–
40 years. Split-liver transplantation grafts demonstrated a
significantly increased relative risk of graft failure and death
vs. cadaver donors aged 18–40 years (68). When strati-
fied by recipient status, UNOS status I SLT recipients also
demonstrated a significantly increased risk of graft fail-
ure and death vs. cadaver whole-organ donors aged 18–
40 years. Significantly increased graft failure of SLT recip-
ients vs. cadaver donors aged 18–40 years was observed
in UNOS status IIB and III as well, but did not translate into
significantly increased deaths (68). Split-liver transplanta-
tion graft data were comparable to the ‘marginal donor’
group with overall graft failure and death not being statis-
tically different. Thus, the splitting of presumptive optimal
donors yielded right SLT grafts that behaved similar to ca-
daver whole-organs procured from ‘marginal donors’ (68).
Comparison of in situ, and ex vivo SLT procurement tech-
niques have not identified a distinct advantage. Morbid-
ity and mortality was comparable between procurement
methods, except for the incidence of postoperative hem-
orrhage, which was higher among ex vivo SLT recipients
in the ASTS survey (60). Data from left lateral segment
grafts suggest a higher incidence of primary nonfunction
among grafts prepared ex vivo vs. in situ or living-donor
(18,20,22–24,69); however, other transplant centers have
reported excellent results performing the ex vivo technique
(22,56,64,70). The authors advocate the in situ technique
prevents inadvertent graft re-warming, simplifies identifi-
cation of vascular and biliary structures, and facilitates graft
sharing by permitting direct graft shipment from the donor
site without additional ex vivo separation.
Obstacles Impeding Further
Utilization of SLT
The success of SLT applied to adult/pediatric pairs in the
present climate of organ scarcity has fueled initiatives to
expand efforts to include two adult recipients from one
1332
adult cadaver donor. However, substantial obstacles must
be overcome prior to the further application of SLT. These
obstacles include technical advancement, logistic, organ
allocation, as well as issues of informed consent. As de-
tailed earlier, SLT requires substantial planning and a su-
perior surgical technique. To date, most SLTs have been
performed in large centers that can support at least two
concurrent recipient operations with experienced surgical
teams. Technical considerations complicating SLT are still
in evolution and must be further disseminated throughout
the surgical community prior to any appreciable increase
above current activity (71).
Split-liver transplantation requires substantial coordination
once a suitable donor is identified. Recipient selection is
principally limited by available left lobe or left lateral seg-
ment mass. Thus, to implement SLT between two adults,
the team contemplating the procedure must have access
to a diversity of recipients of different sizes that can be
paired. This flexibility may require that centers collaborate
to benefit the overall donor pool and compromise on indi-
vidual access for global benefit. In Europe, where cadaver
organs are allocated to centers, rather than specific pa-
tients, increased flexibility is available for recipient selec-
tion and coordination (71). The result has been standing
agreements between centers for sharing of partial grafts
that have been quite successful (31,72). The past UNOS
policy permitting the unrestricted use of remnant grafts by
the SLT center was a direct incentive for the application of
SLT; however, in regions where multiple centers are com-
peting for each donor, rigid allocation policies impede SLT
application.
While we have utilized split-grafts for the treatment of
UNOS status I recipients, we have avoided utilization of
split-grafts in patients with advanced chronic liver disease
requiring intensive care unit hospitalization (UNOS status
IIA) (27). Disappointing results in decompensated cirrhotics
with living donor and SLT grafts have made it apparent that
critically ill patients fare poorly from these complex tech-
nical variants (27); although, previously well patients with
fulminant hepatic failure may prove an exception. Compli-
cations are more frequent and poorly tolerated by the de-
compensated cirrhotic. Ironically, these are the patients to
whom livers are preferentially allocated under the patient-
driven system in the United States (71).
Requirements for consent with respect to SLT have not
been defined. In contrast to the extensive ethical analy-
ses that preceded living donor liver transplantation (73),
relatively little discussion of the ethics surrounding SLT
has occurred. As increased risk is inherent in the perfor-
mance of SLT, it is customary to obtain specific informed
consent for the procedure. Traditionally, patients have not
been involved in the selection of cadaver donors; but the
extended use of ‘marginal’ donors has brought the is-
sue of consent to the forefront. The parameters govern-
ing these issues have not been defined and the boundary
American Journal of Transplantation 2003; 3: 1323–1335

between a marginal or ‘expanded’ donor, and a standard
donor, remains the purview of individual programs (71).
The question of the boundary between technical innova-
tion/improvement and clinical research involving investiga-
tional review committees and separate informed consent
is particularly relevant to SLT. In our view, the issue of SLT
and donor selection should be addressed with the patient
prospectively, when the patient is placed on the wait-list.
Discussion
Organ scarcity and increasing wait-list morbidity were the
impetus for the development of SLT. Today, the discrep-
ancy between organ supply and recipient demand has
never been greater. This has renewed interest in increased
application of traditional adult/pediatric SLT and perfor-
mance of adult/adult SLT. A decade of experience with
left lateral segment grafts has demonstrated that SLT ap-
plied to pediatric recipients yields excellent outcomes with
significant decreases in pediatric wait-list times, wait-list
morbidity, and lower utilization of living-donation at centers
that routinely implement these techniques (27,29,74). Pub-
lished comparisons between children receiving split and
living donor left lateral segment grafts confirm compara-
ble benefits from split liver grafts (27) (53). The benefits
of SLT, without donor risk, make it our preferred technique
for the transplantation of infants and small children without
access to cadaver whole-organs.
Evolution of SLT is the product of Herculean efforts by a se-
lect group of centers around the world who have overcome
significant barriers. Despite these efforts, SLT remains an
infrequent procedure, principally applied in the setting of
adult-pediatric pairs with at least one recipient being criti-
cally ill, that only a handful of U.S. transplant centers rou-
tinely perform. The authors assert that enhanced utiliza-
tion and improved results will only be possible through
improved information sharing, resolution of technical, lo-
gisitic, and public policy issues, as well as liberalization of
allocation criteria to provide transplant centers discretion in
matching donors and recipients with respect to graft mass
and severity of recipient medical status.
The greater than 90% response of transplant centers
to the ASTS survey demonstrates keen interest in SLT.
Clearly, the crisis in organ donation that currently exists is
universal and has heightened awareness of potential av-
enues for increased donation. Despite this widespread in-
terest, only 45% of responding centers reported any ex-
perience with SLT and two-thirds had performed a total of
less than five procedures. Graft sharing between centers
is infrequent: the ASTS survey reported a 5% incidence
of graft sharing between five centers, Yersiz et al. have
reported sharing three left lateral segment and 22 right
trisegment grafts (27), Azoulay et al. has reported sharing
four of 36 SLT grafts (56), and Rela et al. have shared three
of 41 grafts obtained from ex vivo SLT (70). While a ‘learn-
American Journal of Transplantation 2003; 3: 1323–1335
Split-Liver Transplantation
ing curve’ was not assayed by the ASTS survey, it certainly
exists as demonstrated in liver living-donation (50,75). The
unequal distribution of experience, coupled with a required
‘learning curve’, forecast that greater information sharing
must occur prior to SLT achieving a larger role in alleviat-
ing the current organ crisis. Improved information sharing
could stimulate greater center graft sharing that would in-
crease experience and decrease reluctance to accept ad-
ditional SLT grafts for transplantation. The data presented
herein are encouraging; however, the data are unverifiable
with obvious gaps in organ accountability. The lack of an
organized information sharing or education system under-
scores the need for a verifiable, data collection instrument,
to provide information on SLT. This has not been success-
fully implemented despite widespread calls for its creation.
Data from such a registry would be prerequisite for modi-
fication of current allocation criteria. Until this occurs, data
on these procedures will be extremely limited and dissem-
ination inefficient.
The fate of adults who receive trisegment grafts remains
controversial. Two series examined adult right trisegment
recipients by comparing SLT recipients with adults receiv-
ing cadaver whole-organs during the same time period (27)
or via case-matched controls (29). In each study, 1-year
patient survival was comparable between SLT right triseg-
ment and whole-organ recipients. While excellent single-
center data exists, the ASTS survey data and the UNOS Sci-
entific Registry data demonstrate inferior outcomes when
applied to adults in urgent need of liver transplantation. The
ASTS report of 387 split-grafts is the largest collection of
data to date, but is subject to the natural limitations of a
survey that depends upon voluntary participation and self-
reporting. Similarly, the SRTR’s failure to identify specific
SLT grafts and to detail complications limits interpretation.
This question is fundamental for the future of SLT, as com-
parable outcomes between right trisegment grafts and ca-
daver whole-organs in recipients across categories of ur-
gency and indication is prerequisite for SLT to be further
applicable and recognized in allocation policy.
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