Split liver transplantation: split in-situ or ex-situ?

Abstract

Split liver transplantation provides an ideal means of generating size-matched liver grafts for children without reducing the organ pool for adult recipients. In the past 10 years, split liver transplantation enabled clinicians to practically eliminate pediatric waiting list mortality and to reduce morbidity. Two major techniques are applied in liver splitting. Both techniques, ex-situ and in-situ splitting, usually provide a left lateral and a right (extended) liver graft to be transplanted into one child and one adult respectively. The in-situ technique has several advantages from a theoretical point of view, the most important being the shorter ischemia times. The patient and graft survival of in-situ split livers have exceeded 80 to 90% and 75 to 80% respectively, with lower incidence of postoperative complications in comparison to ex-situ grafts. When transplanting elective recipients, excellent results can also be reached with the ex-situ technique. In-situ splitting is the technique of choice for sharing split liver grafts between liver transplant centers, when transplanting non-elective recipients or when performing small-for-size transplantations. Therefore, the in-situ technique is an important advance in the quest to develop split-liver transplantation for two adult recipients.