Introduction: A significant size discrepancy between graft volume and the recipient’s abdominal cavity is a limiting factor for smaller patients to access liver transplantation. Our aim was to report our experience with monosegmental (MSG) and hyperreduced left lateral segment (HRLLS) split grafts to overcome large-for-size-scenarios.
Methods: A retrospective analysis (2019-2023) of HRLLS and MSG graft recipients in split liver transplants (LT).
Results: Out of 41 split liver transplants, 20 patients received 22 conventional LLS grafts (8 female/12 male, mean age and weight of 36.5±34.4 months and 14.2±6.6 kg) and 19 patients received 5 MSG and 14 HRLLS grafts (10 female/9 male, mean age and weight of 8.2±4.6 months and 6.3±1.7 kg). 
End-stage liver disease secondary to progressive cholestasis was the predominant indication for LT in the HRLLS/MSG group (73.7%), versus 45.5% in the LLS-group.  
All patients in the HRLLS/MSG group were first-time graft recipients. Graft-to-recipient weight ratio in the HRLLS/MSG-group was 3.7±0.9%, despite all patients weighing less than 10 kilograms. 
Standard hepatic arterial reconstruction was performed in 33 cases (80.5%). 3 monosegmental graft recipients required an aortohepatic conduit. 
Twelve patients (7 HRLLS/MSG patients) required delayed sequential abdominal wall closure.
During a 25.3±17.8 month follow-up, 2 hepatic artery stenosis were recorded in the HRLLS/MSG-group. All patients in the HRLLS/MSG-group are alive and have functioning grafts. 
Conclusion: Despite being a more technically challenging option, both reduction-types successfully prevented large-for-size and large-for-flow problems in small recipients.