A 50-year-old lady with polycystic liver disease underwent living donor liver transplantation due to recurrent cyst infection. Pre-operative CT scan showed gross hepatomegaly with severe compression of the inferior vena cava (IVC). Liver function was normal. During total hepatectomy, mobilization of the liver was difficult due to severe adhesion at the retrohepatic IVC. Bleeding from retrohepatic veins draining into IVC was encountered. The suprahepatic and infrahepatic vena cava was then clamped after division of the inflow vessels. As the right liver was rotated to expose the retrohepatic vein branches for ligation and division, the IVC was avulsed due to the shear force secondary to the heavy weight of the polycystic liver. A complete tear was noted 2 cm below the suprahepatic IVC clamp with a very thin tissue edge. IVC reconstruction with interpositional cadaveric vein graft was performed to restore the caval continuity. However, the cava was considered unsuitable for anastomosis with the right liver graft venoplasty due to poor tissue quality. As such, the right atrial appendage was approached via opening of the diaphragm. An interpositional polytetrafluoroethylene (PTFE) graft was first anastomosed to the liver graft venoplasty before orthotopic anastomosis between the atrial appendage and the suprarenal IVC (See Figure). The patient recovered well with good return of liver function. Postoperative CT Scan did not reveal any graft thrombosis at 4 months after the operation.