*Purpose: Liver transplantation (LTx) in pediatrics has become an accepted modality for treatment in end-stage liver disease and irreversible acute liver failure. Left lateral segment (LLS) graft from donor hepatic split is most commonly used in pediatric patients. However, the implantation of LLS graft can be a problem, especially in infants after percutaneous endoscopy gastrostomy (PEG), because of the adhesions after previous surgical interventions causing graft shift to the right side of the epigastrium. We used a new “up side down” technique to position LLS graft to the right subphrenic space.

*Methods: Total of 4 LLS liver grafts transplantations with “up side down” method were performed in 4 pediatric patients (2 male, 2 female) over the period 8/2017 – 11/2019. Patients aged from 7 months to 56 months (mean age 34.50 ± 32.47 months), weight 5,8 kg – 38.0 kg (mean weight 14.88 ± 22.99 kg). The indications for LTx was biliary atresia (50%) and metabolic disease (ornithine transcarbamylase deficiency (25%) and glycogenosis (25%)). None of the patients was previously transplanted. The position of the graft was in the right subphrenic space with SII located ventrally, SIII dorsally and gastric impression cranially.

*Results: Overall 4 children were transplanted with a LLS graft using new “up side down” technique. Actually, 3 children are alive (1month, 21 months and 28 months after surgery) with good liver graft function. One patient died (12 months after LTx) because of post-transplant lymphoproliferative disorder.

*Conclusions: We are presenting a new technique for liver transplantation in pediatric patients using LLS grafts. A new “up side down” technique allows us to position liver graft to the right subphrenic space in pediatric recipient. This minimizes risk of graft rotation or shift.

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