The piggyback hepatectomy technique (PGB) is avoided in liver transplant patients with hepatocellular carcinoma (HCC) to decrease the theoretical risk of a positive vena cava margin or hematologic metastases. This study reports the routine use of PGB in 138 consecutive adult, deceased donor liver transplant recipients with HCC. Piggyback hepatectomy technique was used in 119 subjects, with 19 recipients receiving the conventional bicaval technique (CONV). Median follow-up was 34 months. There were 95 patients (69%) within and 43 patients (31%) outside, Milan criteria at transplant. Hepatocellular carcinoma recurrence rate was 13% and survival was 84.1% (1-year) and 77.4% (2-years). The PGB and CONV study groups did not differ in survival within or outside Milan criteria. Cox proportional hazards modeling of posttransplant survival demonstrated statistically similar survival for PGB and CONV. In conclusion, the presence of HCC in liver transplant patients should not preclude the use of PGB.