Graft Optimization through Ex Vivo Resection of Multifocal FNH in a Deceased Donor Liver: Technical Approach and Clinical Outcome

Focal nodular hyperplasia (FNH) is a benign hepatocellular lesion with negligible malignant potential, but multifocal disease in deceased donor livers creates diagnostic uncertainty and frequent graft discard in the context of organ shortage. This report describes graft optimization through ex vivo resection of multifocal FNH in a young deceased donor, enabling safe utilization of an otherwise rejected graft. A 22-year-old woman with normal liver biochemistry had a macroscopically normal liver except for seven nodules mapped by intraoperative ultrasound across segments II–III, IV, caudate, and deep right lobe parenchyma. Frozen section of a 2.5 cm segment IV lesion confirmed FNH, prompting graft acceptance and bench surgery. Non-anatomical, parenchyma-sparing wedge resections of seg II/III and caudate lesions were performed ex vivo, preserving approximately 85–90% functional parenchyma, while three small deep right-lobe nodules were left in situ for surveillance. The graft was transplanted into a high-MELD recipient with decompensated alcoholic cirrhosis, with cold and warm ischemia times of 155 and 40 minutes and uneventful reperfusion. Early and 6-month outcomes demonstrated excellent graft function, patent vasculature, and no lesion-related complications. This case highlights a pragmatic, technically reproducible strategy to expand the donor pool by combining frozen-section–anchored diagnosis with selective ex vivo resection for multifocal benign lesions.