Traditionally, liver transplantation is performed using cadaveric whole-organ donors. Although liver diseases leading to liver transplant are more prevalent in adults, the discrepancy between the number of recipients and the number of donors is much greater in the pediatric population. This resulted in a mortality rate of 30% for patients waiting on the pediatric list. In 1983, the first segmental liver transplantation was performed in which an adult cadaveric liver was size-reduced to fit a smaller pediatric patient. In size reduction, either lobe of the graft is resected and discarded after procurement. The liver segment selected to fit the patient, from the left lobe, left lateral segment, or right lobe is transplanted into the child. The development of this technique greatly contributed to a reduction of mortality among children waiting for liver transplantation. Although the problem of organ shortage for pediatric patients was solved with this approach, the diversion of liver grafts from adults to children further disadvantaged adult patients.

This led to the development of the split-liver technique. With this approach, the liver graft is divided into two grafts. This is achieved by performing liver resection with preservation of vascular pedicle (or supply) and the bile duct to each lobe or segment. After the splitting procedure is completed, two grafts are obtained and transplanted into two recipients. Graft splitting can be performed on the bench after procurement (ex-vivo split) or in the donor before liver preservation (in-situ split). In split-liver transplantation, two patients (usually an adult-child pair) receive the benefit from one donor. Although, the idea of split livers sounds promising, it did not make the expected impact on organ shortage due to limited number of ideal donor livers that can tolerate the split procedure. There were also significant complication rates that impacted the short- and long-term results. With further improvements in this technique, the results are expected to improve.

The live-donor approach during the past decade developed as a logical extension of segmental liver transplantation. It was initially implemented in pediatric patients where the live donor's left lateral segmentectomy (usually 25% of liver volume) was performed with preservation of the vascular pedicle during transection of the liver parenchyma. The technique of the procedure is as follows: Complete hemostasis is achieved before the graft segment of the liver is detached and perfused with preservation solution. In the recipient, the diseased liver is removed while the vena cava is preserved. The graft segment is placed in the orthotopic location and the left hepatic vein is anastomosed to the vena cava end-to-side (piggy-back technique). The portal vein of recipient is then connected to left portal vein of the graft by end-to-end anastomosis. The liver is reperfused at that point. The donor's left hepatic artery is anastomosed to hepatic artery of the recipient using a microvascular technique under the surgical microscope. Lastly, the bile duct of the graft is anastomosed to Roux-en-Y loop of the small intestine.

Auxiliary orthotopic liver transplantation is one of the most recent surgical techniques. The initial, and probably the best, application is for the treatment of fulminant hepatic failure. With this technique, a segment of the native diseased liver of the recipient is resected to accommodate a segmental liver graft (usually from a live donor). For example, a left lobectomy is performed in a pediatric recipient and the left lateral segment is transplanted in exactly the same position. In fulminant liver failure, frequently, the native liver may regenerate and recover over time. Once the function of the native liver is restored, the immunosuppressive drugs can be stopped and the auxiliary graft usually rejects and undergoes atrophy. In cases where the native liver function does not return, long-term immunosuppression is continued just as in whole-liver cadaveric transplants.

The surgical technique of liver transplantation has evolved from whole organ to segmental transplantation. The utilization of live donors yields liver grafts of better quality and expeditious engraftment. These refined techniques combined with newer agents and improved immunosuppression regimens are expected to result in more than 90% one-year graft and patient survival.