In many fields, the introduction of microsurgery has dramatically helped patients. Replants, free tissue transfers and other applications of microsurgery have saved countless lives, and limbs. The emerging field of pediatric liver transplantation is another new frontier where microsurgery has helped save lives, as smaller and smaller recipients are enabled to successfully receive smaller livers, and even "split" donor livers, instead of lingering on transplant lists until death. In previous reports, the major cause of morbidity and graft loss in pediatric liver transplantation has been hepatic artery thrombosis. Prior to the introduction of microsurgery techniques, the incidence of hepatic artery thrombosis and mortality in pediatric liver transplantation has been reported to approach 50%. The risk of hepatic artery thrombosis is even more significant in living related, "split" liver transplantations, because of the graft artery's small diameter, short length and high incidence of anatomic variation and size mismatch. Since the recent adaptation of microsurgical techniques to hepatic artery anastomosis in liver transplant surgery, the mortality has plummeted. At the University of California at San Diego, the pediatric liver transplant team collaborated with the plastic surgery/microsurgery team to adapt microvascular techniques to our pediatric liver transplant cases. We noted a significant improvement in our own series' results with this two-team combination. As with previous successful collaborations between transplant and plastic surgeons (when Merrill and colleagues won the Nobel prize for the first successful human kidney transplant), we also demonstrate improved results with this combination of specialists.

From May of 1999 to June of 2001, our combined team performed 9 liver transplant cases (6 living related "split" liver transplants, 3 cadaveric liver transplants) using microsurgical anastomosis and reconstruction of the hepatic artery. We incurred no hepatic thromboses during this period. One recipient died of a primary nonfunctioning graft. All other recipients are alive and well at 2 years post transplantation: a significant improvement not only within our own center, but also a favorable result when compared to other previously reported pediatric liver transplant series.

This study reports our initial experience with combining these two separate surgical disciplines, using microsurgery and applying it to innovative liver transplant procedures. We also present some of the unique technical difficulties encountered in this type of combined surgical procedure, when compared to our usual applications of microsurgery (free tissue transfers and replants).