*Purpose: For living donor liver transplantation, preoperative imaging is required for the safety of donor and recipient. As we started our image-guidance program using 2D illustrations and 3D modeling since September 2018, we analyzed the changes in the clinical outcomes.

*Methods: Living donors and recipients who underwent liver transplantation between September of 2017 to August 2019 were included. Cases with image-guidance were compared to cases without image-guidance regarding operational outcome especially bile duct opening in graft as well as surgical complications.

*Results: Among 200 living donor transplantation, 90 transplantations were performed with image-guidance. The image-guidance group had higher rate of laparoscopy (80.9 vs. 97.8%, P<0.001) and shorter operation time (259.8±47.3 vs. 240.3±34.4 minutes, P=0.002) compared to the no image-guidance group. Although there was no difference in bile duct type (P=0.144), there was more grafts with single bile duct opening in the image-guidance group (52.7% vs. 80.0%, P=0.001). Consequently, achievement in bile duct openings was superior in the image guidance group. (P=0.022) There were no difference in bile leakage, graft failure, and death during the 1-month post-transplantation period.

*Conclusions: As we initiated our image-guidance program for living donor liver transplantation, clinical outcomes, especially bile duct division were improved than before.

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