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Park, et al.
the body size of the donor and recipient was similar in respectively. When we fit the printed graft to the printed
this case, female recipients with a small body size are abdominal cavity, the right hemi-liver graft seemed
always under the risk of large-for-size syndrome since too large to be transplanted. Therefore, we decided to
allocation can be matched to male donor. Therefore, in use extended left liver graft for transplantation and the
our center, female patients with high model for end-stage operation was successfully carried out (Figure 3E, Case
liver disease (MELD) scores with a potential for being No. 13 in Table 2).
matched to a deceased donor were prepared for 3D model An 8-year-old female with Wilson’s disease was
printing in case of donor match. allocated for split LT from a 16-year-old male donor
A 44-year-old female of 158 cm and 43 kg had who had a weight of 94 kg. The 3D printed model was
alcoholic liver cirrhosis and underwent graft failure used during procurement to guide the surgeon to choose
due to non-compliance after LDLT. The initial plan between using left lateral graft and left hemigraft. The
was for her to receive a whole liver graft from a male team decided to use a left hemiliver which weighted
donor (height: 173 cm and weight: 66 kg). However, 657 g and GRWR was measured to be 2.28%. Split LT for
after visual comparison to the 3D printed model, the size pediatric recipients is considered to be the most valuable
of the graft seemed too large to fit into the recipient’s circumstance that the model can be useful (Figure 3F,
abdominal cavity. Therefore, we decided to use reduced Case No 15. in Table 2).
extended right hemi-liver graft, and the graft fitted well
with no large-for-size syndrome (Figure 3B, Case No. 1 4. Discussion
in Table 2). Large-for-size syndrome is a rare but devastating
A 6-month-old boy who underwent Kasai operation condition that can interfere with the survival of both
due to biliary atresia eventually had liver failure; the graft and the recipient . During deceased donor LT
[11]
therefore, his father and mother were examined to (DDLT), the size mismatch between the donor’s liver and
see if they could serve as living donors. The estimated recipient’s abdominal cavity can occur due to the limited
liver volumes of father and mother were 232 cm and evaluation of both the donor and recipient . Although
3
[12]
201 cm , respectively, and GRWRs were 3.32 and the chance is low, since CT scan is not a routine evaluation
3
2.87, respectively. After comparing the 3D printed liver procedure for deceased donors in Republic of Korea
grafts of both candidates with the recipient’s 3D printed for protecting the kidney from contrast-induced kidney
abdominal cavity, we finally decided to use liver graft from injury, there is a risk for the occurrence of large-for-size
the recipient’s father. During the back-table procedure, syndrome especially in small female recipients matched
actual liver graft was placed in the 3D abdominal cavity to male donors. The decision to perform LT using the
model and reduction of the graft liver was done so that graft or to reduce the graft should be decided based on
it fits perfectly in the recipient’s actual abdominal cavity the understanding of the size of the recipient’s abdominal
(Figure 3C, Case No. 3 in Table 2). cavity. However, in most cases, the donor and recipient
A 4-month-old boy with acute liver failure due are operated in different hospitals. Therefore, the donor
to ornithine transcarbamylase deficiency was initially surgeon should decide whether the graft is in adequate size
planned to receive S2 monosegment graft from his father. based on the visual examination of the graft liver without
The estimated S2 monosegment graft volume and GRWR actual visual comparison of the recipient’s abdominal
were 194 cm and 3.03 cm , respectively. As shown in cavity. The rarity of large-for-size syndrome justifies the
3
3
Figure 3D, 3D printed liver graft was too large to fit into limited number of published studies . By calculating the
[13]
the 3D printed abdominal cavity. The newly produced diameter of the right hemi-abdomen where the liver will
3D printed reduced graft seemed suitable, and the actual be placed can be helpful for the decision. However, while
reduced liver graft fit perfectly into the 3D abdominal experienced surgeons can manage to perform adequate
cavity model, leading to successful transplantation to the decision making with limited information, surgeons in
recipient (Figure 3D, Case No. 10 in Table 2). their learning curve need more assistance not to make
A 61-year-old female with liver cirrhosis due to a mistake during the decision process. Therefore, we
hepatitis C had chronic empyema of the right hemi-thorax, managed to utilize 3D printing technology to build a 3D
which was followed by contracture of the right liver printed model of the intra-abdominal cavity to its actual
fossa. Because of the extremely small abdominal cavity, size.
the first matched deceased donor graft was aborted after 3D printing technology has been applied in the field of
comparing it with 3D printed abdominal cavity model. liver surgery and several studies have been published [8,14] .
LDLT was planned, and 3D printed right liver graft and However, most studies focused on liver malignancy to
left liver graft model were printed to choose a proper print the cancer on its actual location in relation to the
graft for the recipient’s abdominal cavity. The GRWRs adjacent anatomical structures [15-17] . These approaches
of the right and left hemi-livers were 1.63 and 0.97, seem valuable as it can print the liver and cancer mass

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