The small-for-size syndrome (SFSS) presents a persistent problem for living donor liver transplantation (LDLT) with small grafts, especially left lobe grafts (LLG) (H1234-MHV). Here, researchers show that slight alterations to standard surgical procedures can significantly enhance results when dealing with tiny grafts. About 130 adults LDLT were conducted in a single enterprise between 2012 and 2020, with 61 LLG (H1234-MHV) accounting for 47% of the total. The ratio of the graft to recipient weight was 0.84%, less than the 0.7% range accounting for 22% of transplants. About 62 patients (56%), both before (n=50) and after (n=22) graft reperfusion, underwent splenectomy to regulate input. All 3 of the recipient’s hepatic veins were used to facilitate venous outflow in LLG-LDLT. To do the right lobe graft (H5678) (RLG)-LDLT, a big cavotomy was made in the recipient, and the graft’s right hepatic vein was anastomosed to the cava. The Short-Term Allograft Survival Score (SFSS), Early Allograft Dysfunction (EAD), and Survival are all indices of success. There were no significant differences between LLG (H1234-MHV) and RLG in graft survival at 1, 3, and 5 years 94%, 90%, and 83% (H5678). The portal blood flow was drastically decreased after splenectomy, and there was no increase in complications. Only 1 patient (0.8%) experienced SFSS, and 18 patients (13.8%) experienced EAD despite the heavy reliance on tiny grafts. After controlling for confounding variables, multivariate logistic regression identified the MELD score and LLG (H1234-MHV) as independent risk factors for EAD, while splenectomy was found to be protective (odds ratio: 0.09; P=0.03). Patients who underwent prereperfusion splenectomy for LLG (H1234-MHV)-LDLT had a higher rate of graft survival at 1 year compared to those who got postreperfusion splenectomy. In adult LDLT, LLG (H1234-MHV) is possible and has great outcomes that are on par with RLG (H5678). The barrier to employing small-for-size grafts can be lowered by performing a splenectomy or enhancing venous outflow.