Early Graft Function After Intraoperative Assessment–Guided Selective Ligation of Segment 5/8 Veins in Adult Right Lobe Living Donor Liver Transplantation

Background Reconstruction of segment 5 and/or segment 8 anterior sector veins ≥5 mm is commonly recommended in adult right lobe living donor liver transplantation to prevent venous congestion. However, the necessity of routine reconstruction remains controversial. Methods In this retrospective cohort study, adult recipients who underwent right lobe living donor liver transplantation without inclusion of the middle hepatic vein at a high-volume transplant center between November 2021 and May 2025 were analyzed. Patients with intraoperatively measured segment 5 and/or segment 8 veins ≥5 mm were included. Venous management was determined intraoperatively and was not randomized. Patients underwent either venous reconstruction or selective ligation based on functional graft assessment. Early graft function on postoperative day 7 was evaluated using international normalized ratio, total bilirubin, and ascites volume. Multivariable linear regression analysis was performed to adjust for potential confounders, including graft-to-recipient weight ratio (GRWR) and Model for End-Stage Liver Disease (MELD) score. Results A total of 175 recipients were included (16 in the selective ligation group and 159 in the reconstruction group). Baseline demographic and clinical characteristics were comparable between groups. Early graft function parameters on postoperative day 7 did not differ significantly between groups for international normalized ratio (1.24 vs 1.27; p = 0.83), total bilirubin (1.46 vs 1.71 mg/dL; p = 0.30), or ascites volume (1100 vs 1245 mL; p = 0.88). In multivariable analysis adjusting for GRWR and MELD score, selective ligation was not independently associated with increased postoperative ascites (β = 0.214; 95% CI −0.334 to 0.762; p = 0.445). In a sensitivity analysis restricted to recipients with GRWR ≥0.8, results remained consistent (β = 0.242; p = 0.407). Conclusions Selective ligation of segment 5 and/or segment 8 veins ≥5 mm, when guided by intraoperative functional assessment, was not associated with impaired early graft function. Routine reconstruction of all anterior sector veins ≥5 mm may not be mandatory in carefully selected recipients with adequate graft volume and satisfactory perfusion. Clinical trial number: not applicable.