*Purpose: Adequate graft portal venous flow is essential for the rapid regeneration of partial grafts during living donor liver transplantation (LDLT). Large splenorenal shunts (SRS) can induce a steal phenomenon that diminishes graft portal venous flow, resulting in graft dysfunction, hepatic encephalopathy or portal vein thrombosis. There is controversy as to whether these shunts should be occluded during the transplant procedure. Furthermore, in LDLT, closure of large SRS may increase excessively the portal pressure and shear stress of the small partial graft and result in small-for-size-syndrome (SFSS).

*Methods: Herein we report three patients with large SRS who received proximal splenic vein ligation during LDLT to ensure adequate portal inflow.

*Results: Preoperative CT scan showed large SRS with small caliber portal veins. The mean native portal flow was 133.33 ± 33.33 mL/minute (range, 100 – 200 mL/minute). The mean graft weight was 610 ± 20.81 g (range, 580 – 600 g) and the mean graft-to-recipient weight ratio (GRWR) was 0.83 ± 0.02 % (range, 0.80 – 0.87 %). The mean portal flow following reperfusion was 1000 ± 264.57 mL/minute (range, 500 – 1400 mL/minute) and it increased to 2266.66 ± 933.33 mL/minute (range, 800 – 4000 mL/minute) after ligation of the proximal splenic vein. The splenic vein was approached infrapancreatically after tunneling of the superior mesenteric vein. All patients maintained adequate portal vein flow during the early post-operative period. None developed SFSS or excessive amount of ascites drainage. Post-operative CT scan showed good liver regeneration, patent portal veins with single inflow from the superior mesenteric vein and decompression of the splenic vein and SRS.

*Conclusions: In conclusion, intraoperative ligation of the proximal splenic vein represents an effective procedure to keep adequate portal vein flow in patients with large SRS.

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