[Domino and split liver transplantation: technical problems]

Because the shortage of donor livers has been the rate-limiting factor in the expansion of liver transplantation, several innovative techniques including reduced, split, and living donor liver transplantation have been developed to expand the relatively constant pool of organs. Domino liver transplantation, which was first reported from Portugal in 1995, has been performed worldwide and allows a donor organ to be used for a subsequent graft in a second liver recipient. Domino liver transplantation involves specific ethical and technical problems. The most important ethical problem in the procedure is the use of a diseased liver (e.g., familial amyloid polyneuropathy [FAP]) for a second recipient. Furthermore, the safety of the first recipient (FAP patient) should be the primary consideration. From the technical point of view, the management of short vascular cuffs is important, especially in domino liver transplantation from a living donor. The results of split liver transplantation have significantly improved and it is now recognized as an ideal method to expand the donor pool, especially for small children. Either the ex vivo or in vivo technique can be used with comparable results.