Over the last 30 years split-liver transplantation has become a victim of its own success. The shortage of organs and the resulting death risk during the waiting time has become the most important factor for survival in many indications.

Apart from direct measures to increase donation the transplant surgeon has several ways to deal with this. First of all we tailor indications to the availability of organs. Further we can try to open resources by transplanting extended criteria donor grafts or livers from DCD donors. Finally we can use technical options like domino transplantation, split-liver transplantation or living donor liver transplantation.

Split-liver transplantation started in the end of the 80s with the aim of providing grafts for children, then the most deprived group of patients. The technique was hampered by bad results for the right graft and poor reproducibility. In 1995 the experience with living donor liver transplantation translated in the introduction of in-situ splitting. This technique was completely designed to safeguard the right graft. During this initial period, single experiences of experienced centers showed similar results for split- and whole grafts, while registry data still clearly identified split-liver transplantation as a risk factor for the adult recipient. This situation is now turned around with registry data, both in Europe and the US, confirming comparable results in the last years while inferior results are only reported by a few centers.

While this way of splitting has practically solved the organ availability for children and preserves the numbers of grafts for adults, our ultimate goal should be to develop split-liver transplantation for two adults. Despite several technical improvements, the size of the grafts and the damage to the vascularisation of the bile ducts remains a problem. Split-liver transplantation for two adults is therefore a procedure in development with large potential if the small-for-size problem can be solved.

In view of our increasing willingness to accept ECD donor organs we should be willing to look at our best organs and make optimal use of them.