Background: Patients undergoing liver transplantation (LT) are routinely assessed for surgical difficulty, but the predictive value of these assessments are inconsistent. We quantified risk factors for surgical complexity in LT to inform decision making and assist in perioperative planning.

Objective: To risk stratify surgical difficulty in liver transplantation.

Methods: Our prospective LT database (2012–2023) was analysed comparing patients based on surgical difficulty, defined by three surrogate measures (operating time, blood loss, intraoperative complications). Patients were stratified into low (LD), intermediate (ID) and high (HD) difficulty cohorts and compared based on demographic, biochemical, surgical and radiological data. Statistical analysis included ANOVA and chi-square test with multivariate regression to control for covariates.

Results: A total of 771 transplants were included in the study (LD, n = 225; ID, n = 346; HD, n = 200). High-difficulty LT was associated with worse overall survival (HD 85.5%, ID 93.7%, LD 96.4%, p < 0.001) and graft failure (HD 6.5%, ID 2.0%, LD 0.9%, p < 0.001), prolonged hospitalisation and complication rate. Factors predictive of surgical difficulty were multiple prior abdominal surgical procedures (>1, OR 1.94, p < 0.05), prior open hepatobiliary surgery (OR 3.86, p < 0.05), re-transplantation (OR 5.89, p < 0.05) and prior spontaneous bacterial peritonitis (OR 3.04, p < 0.05)

Conclusion: Four variables were associated with significant risk for surgical complexity in LT. These variables have been included into a score with preoperative utility to inform patient risks and plan perioperative resources, but requires external validation prior to clinical implementation.