Ex-Situ Dual Hypothermic Oxygenated Machine Perfusion in Full-Left-Full-Right Split Liver Transplantation for Two Adult Recipients

<b>Background/Objectives</b>: The shortage of liver grafts remains a major challenge in transplantation. Full-left-full-right (FLFR) split liver transplantation (SLT) expands the donor pool by providing two grafts for small adult recipients. However, prolonged cold ischemia time (CIT) and ischemia-reperfusion injury (IRI) limit its success. <b>Methods</b>: We report a case of FLFR SLT utilizing ex situ dual hypothermic oxygenated machine perfusion (DHOPE) to mitigate IRI and enhance graft viability. A brain-dead donor's liver was split under continuous DHOPE, followed by simultaneous transplantation into two adult recipients. <b>Results</b>: Both recipients exhibited stable graft function at one-year follow-up. DHOPE effectively reduced CIT and optimized postoperative recovery, with no major complications beyond Clavien-Dindo Grade IIIb. <b>Conclusions</b>: This is the first reported FLFR SLT using ex situ DHOPE for two adult recipients, demonstrating its feasibility in reducing CIT and improving outcomes. Machine perfusion may become a standard in FLFR SLT.