ObjectiveTo examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. Summary Background DataThe standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). MethodsA prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. ResultsThe analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. ConclusionsThese data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.The results of orthotopic liver transplantation (OLT) in patients with end-stage liver disease continue to improve 1 because of refinements in surgical technique, advances in perioperative monitoring and management, and more effective immunosuppressive protocols. OLT is unique in that the recipient undergoes a substantial hemodynamic challenge during surgery, which is reflected in the complications and postoperative course. Venovenous bypass (VVB) is used in most cases of OLT to facilitate hemodynamic stability.2,3 Despite its usefulness, VVB is associated with unique complications such as thromboembolic complications, air embolus, wound seromas, and infections, and the added costs of the machine, catheters, and extra person-