The Hyper-Reduction Technique to Extend the Limits of Liver Transplantation in Children

The death rate of patients on the waiting list is still one of the main problems of pediatric liver transplantation. Organ shortage is mainly linked to the lack of adequate donors with size-matched organs. Various techniques have been developed to reduce the size of the graft. Recent progress in liver resection techniques allowed the application of these reduction techniques, such as the use of the left lateral segment, split liver transplantation and living related donor technique. These techniques reach their highest expression in the hyper-reduction technique, through which the left lateral segment is reduced to a graft composed of part of segments II and III. This technique allows performing a tailored-made reduction of graft prior to procurement from the donor, according to the volumetric needs of the recipient, thus solving the problem in patients with less than 10 kg. We first described the in-situ hyper-reduction technique during a transplant from a living related donor. In the present report we present in detail, step-by-step, the various technical aspects of our surgical strategy of hepatic hyper-reduction, adding some technical tips and tricks to facilitate this procedure and reduce the risk of complications. The systematic application of this technique (later extended to cadaveric donors) in children with low weight has expanded the indication for transplantation to patients less than 10 kg.