*Purpose: Simultaneous splenectomy with living donor liver transplantation (LDLT) is widely used in Asian countries to decrease the risk of small-for-size syndrome (SFSS). However, the impact and adverse effect of splenectomy on LDLT recipients have not been well studied in Western countries. Herein, we report our series of simultaneous splenectomy to define its impact.

*Methods: Between 2012 and 2020, LDLT was performed in 118 adults using 53 left-lobe grafts (45%) with median graft-to-recipient weight ratio (GRWR) of 0.84, ranging 0.49-1.5. Very small grafts with GRWR ≤0.7 were utilized in 26 LDLT (22%). Total of 66 (56%) patients received splenectomy before implantation of the allograft based on pre-operative risk factors (n=44) or after implantation because of portal hyper-perfusion (n=22). Complications related to splenectomy, incidence of SFSS, graft survival and the risk of early graft dysfunction (EGD) were analyzed. Furthermore, the impact of pre-implantation splenectomy opposed to post-implantation was assessed.

*Results: There was no increase in surgical, thrombotic or infectious complications after simultaneous splenectomy compared to no-splenectomy group. Overall graft survival was 94%, 90%, and 84% at 1-, 3-, and 5-years, respectively with no difference between splenectomy and no-splenectomy group. Despite the aggressive use of small graft, SFSS developed in only one patient and EGD was observed in 15 patients (13%). Multivariable Cox regression revealed MELD score and left-lobe graft as independent risk factors of EGD and splenectomy as a protective factor (odds ratio, 0.104; p=0.036). Furthermore, among patients who received left-lobe, small grafts (GRWR ≤ 0.8), or grafts from donor age ≥ 40 years, patients who underwent pre-implantation splenectomy had better 1-year survival rate than those receiving post-implantation splenectomy.

*Conclusions: Favorable overall graft survival with mitigated risk of graft dysfunction can be achieved with simultaneous splenectomy in LDLT using small grafts. Pre-implantation splenectomy may have a protective effect especially for grafts with an increased risk of SFSS.

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