We report our experience in adult-to-adult right hepatic lobe living donor liver transplantation (ALDLT) using extension of the hepatectomy transection line medially to incorporate the right middle hepatic vein branches into the donor graft. One hundred and nine ALDLT were performed at the University of Colorado from August 1997 to December 2005. Donors were screened preoperatively for hepatic venous anatomy compatible with this technique. Of the 109 ALDLT, the first 10 did not include the right middle hepatic vein branches in the graft. As such, three patients required retransplantation, two from graft loss because of venous congestion. Of the next 99 transplants, only 11 required retransplantation and none because of venous congestion. This approach allows adequate venous outflow through the right hepatic vein more than 1 cm, which is demonstrated by the absence of graft loss from venous congestion and superior graft survival.