Critical & Organ Care · 1989
First Successful Living-Donor Liver Transplant
Liver transplantation had been a clinical reality since Thomas Starzl's first attempts in 1963, but through the 1980s the procedure remained constrained by organ availability. For adults, the waiting list was a serious bottleneck; for infants and small children, it was often fatal. Cadaveric livers from size-matched pediatric donors were rare, and the smaller the recipient, the longer the wait. Biliary atresia, the most common cause of pediatric liver failure requiring transplantation, progressed relentlessly, and many children deteriorated or died before a suitable organ became available.
Russell Strong, a transplant surgeon at Princess Alexandra Hospital in Brisbane, Australia, had been working on the concept of partial liver transplantation to address the pediatric size mismatch. The liver's well-documented capacity for regeneration meant that a donor could, in principle, give a portion of the organ and recover normal hepatic function within weeks. On June 13, 1989, Strong's team performed the procedure: a mother donated the left lateral segment of her liver to her 11-month-old son, who had biliary atresia. Both the donor and recipient survived, and the child's postoperative course was uncomplicated.
The surgical principles that made the operation possible were not new in isolation. Partial hepatectomy was a standard oncological procedure, and the anatomy of segmental liver resection had been formalized through the work of Henri Bismuth and Claude Couinaud in France. What Strong's team accomplished was the combination of partial resection, living donation, and successful transplantation into a pediatric recipient, all carried out without precedent in human patients. The procedure required meticulous dissection of the left lateral segment, preservation of the hepatic vasculature and bile duct, and confident anesthetic and intensive care management of both a living adult donor and a critically ill infant.
Strong's report attracted immediate attention from transplant centers that had been struggling with the pediatric organ shortage. Centers in Chicago, Tokyo, Kyoto, and Paris moved rapidly to replicate and refine the technique. Christoph Broelsch at the University of Chicago, who had contributed substantially to reduced-size cadaveric liver transplantation, extended living-donor work to infant recipients in the United States. Japanese surgeons including Koichi Tanaka in Kyoto developed expertise that would eventually expand to adult-to-adult living-donor transplantation, where larger segments including the right lobe are transferred.
The expansion to adult recipients brought new ethical and surgical complexity. Donating the right lobe of the liver carries substantially more risk to the donor than the left lateral segment donated from adult to infant. Reports of donor deaths and serious complications prompted intensive debate in the transplant community about donor selection, informed consent, and center volume requirements. Regulatory frameworks developed over the following decade to formalize donor evaluation and outcomes reporting. Despite these difficulties, living-donor liver transplantation now accounts for a significant fraction of liver transplants performed globally, particularly in countries with low rates of deceased donation.
Key People
- Russell Strong — Brisbane surgeon who performed the first successful living-donor liver transplant
- Christoph Broelsch — Chicago transplant surgeon who extended living-donor liver techniques in the United States
- Koichi Tanaka — Kyoto surgeon who developed adult-to-adult living-donor liver transplantation in Japan
N Engl J Med, 1990
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