*Purpose: Living donor liver transplantation (LDLT) is a well-established alternative to alleviate postmortem organ shortage in pediatric liver transplantation. Such program, however, should be performed under strict ethical guidelines, and optimal living donor (LD) safety. In spite of left lobe or left lateral liver resection are very standardized surgical procedures in pediatric LDLT programs with minimal morbidity and almost no mortality, we hypothesized that serious unexpected peri-operative medical and/or surgical events during LD procedure indeed occur in a high volume LDLT center, being a major threat to donor safety.

*Methods: From July 1993 to October 2018, 433 paediatric LDLT were performed in our institution under a very strict ethical and clinical protocol. LD medical records were retrospectively reviewed searching for preoperatory donor data, surgical and outcome and the occurrence of perioperative near-miss events (NME). NME was defined as any potentially perioperative harmful event that was identified and controlled before definitive patient or recipient harm has happened.

*Results: There was no mortality in our series. Morbidity consisted mainly in cut-surface collections, transient pleural effusions, in less than 3% each and few incisional hernias. Eight (1,8%) intraoperative NME occurred in LDs: accidental vena cava clamp releasing, left hepatic artery (HA) clip sliding both resulting in massive intraoperative bleeding, donor right HA ligature and section, accidental section of left HA at liver graft hilum, tension pneumothorax during right subclavian vein catheterization, LD intravenous full-heparinization before left portal vein clamping, section of donor common hepatic duct, injury of segment II bile duct at the graft cut surface. NME management consisted in: vascular control of intraoperative bleeding and microsurgical repair of arterial lesions, pneumothorax drainage, intravenous protamine administration, Roux-en-Y hepaticojejunostomy reconstruction, repair of segment II bile duct injury at back-table. None of these NME resulted in postoperative morbidity.

*Conclusions: Despite our minimal morbidity and no mortality rates, unexpected potentially life-threating intraoperative events occurred in our 433 left lobe hepatectomies. 8 serious and potential harmful NMEs were identified in this series. All NME were timely recognised and controlled without subsequent donor or recipient lasting harm. NMEs systematic debriefing led to safety refinements in our LD protocol. Systematic record of LD/NME may be used as quality control tool to assess donor safety in LDLT programs.

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