Living donor liver transplantation (LDLT) was first performed for pediatric patients, for whom the gap between demand and supply of deceased donor liver grafts was large. With excellent graft and patient survival and proven donor safety, application of LDLT has been expanded from pediatric to adult patients.[1, 2] Between June 1990 and June 2008, a total of 1333 LDLTs were performed at Kyoto University, including 616 adult patients aged more than 18 years. The 5-year patient survival rates have been 81% for pediatric and 68% for adult patients. The survival rates were as lower as 66% within a year for adult patients operated on between 1994 and 2000. Such a high mortality immediately after operation has been a significant problem for adult LDLT. To lower the immediate mortality and improve transplant outcomes, several technical evolutions and refinements of perioperative patient managements have been undertaken. Of these, strategies for small-for-size graft syndrome and ABO blood type mismatch represent the most important issues.