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Background: In situ right and left lobe cadaveric split liver transplantation for two adult recipients is a challenging and infrequently performed procedure to increase the liver donor pool. It should be considered for small sized adult recipients who do not have living donors and coming from regions with few donors. In situ split gives the additional advantage of reduced cold ischemia time, better delineation of hilar structures during warm dissection, improved assessment of viability of liver lobes, reduced perioperative bleeding during transplantation and possibly reduced biliary complication rates as compared to ex vivo split. Case report: We will share with you this uncommon procedure which enabled our two small sized adult recipients, who did not have living donors, to receive timely liver transplantation within a short waiting time. The cadaveric donor’s age, body mass index, pressor requirements were all within acceptable limits for this surgery. After laparotomy and satisfactory visualization of the liver we split the liver in to full right and left lobe using techniques used for living donor hepatectomy. The two full hemi livers were then transplanted to two adult recipients who required liver transplantation. After six months follow up, both patients have good graft function with no evidence of small for size, biliary or vascular complications. One recipient is following up as outpatient while the other required readmission for pulmonary complications and is currently recovering. Conclusion: Availability of an ideal cadaveric donor, effective communication between the various teams, appropriate use of radiological tools, meticulous planning and incorporating techniques used in living donor liver transplantation helped us to overcome the various technical and logistic challenges. Ethical dilemma of a shorter waiting time versus smaller graft size needs to be resolved.

Challenges and Lessons Learned from the First Case of In Situ Cadaveric Split Liver Transplantation to Two Adult Recipients in Saudi Arabia