Background : ABO incompatible living donor liver transplantation (ABOi LDLT) is breakthrough to expand living donor pool. However, immunologic problem and small-for-size graft (SFSG) is limitation of ABOi LDLT. Splenectomy is an option to resolve this limitation, but its effect remains controversial. We aimed to elucidate the feasibility of simultaneous splenectomy in ABOi LDLT with SFSG.

Methods : From June 2022 to December 2024, 24 case of ABOi LDLT was performed. Among them, cases that recipient’s massive ascites or graft-recipient weight ratio (GRWR) less than 0.8 were 10. Simultaneous splenectomy with LT was 4 cases.

Results : We compared splenectomy cases to spleen-preserving cases, decrease in isoagglutinin titer was faster in splenectomy cases. Peak total bilirubin level, and PT-INR were low in splenectomy cases. Recipient’s ascites after LT well controlled or lasted short period in splenectomy cases.

Conclusions : Splenectomy with LT caused greater risk of infection and portal vein thrombosis. But, in selected cases, splenectomy is prophylaxis of graft dysfunction and rejection in ABOi LT. when a small graft is predicted preoperatively, or for patients with portal hypertension, simultaneous splenectomy was recommended to prevent SFSG syndrome.