Over the past six decades, liver transplantation (LT) in Japan has evolved from an experimental surgery to a globally recognized model of ethical and technical excellence. Following the world's first LT in 1963, Japan's early progress was impeded by the 1968 "Wada heart transplant" controversy, which suspended brain-dead donation for more than 30 years. This personal viewpoint reviews the historical development of LT in Japan, focusing on the emergence of living donor liver transplantation (LDLT), key technical innovations, legislative changes, and international contributions-particularly in pediatric transplantation. During this period, Japanese surgeons-many of whom were trained in Western centers-pioneered living donor liver transplantation (LDLT), introducing microsurgical techniques for hepatic artery anastomosis and innovative size-reduction procedures that enabled successful grafting even in infants weighing under 5 kg. Pediatric LDLT became the foundation for adult applications, achieving outstanding long-term outcomes. The Organ Transplant Law (1997) and its 2010 revision gradually permitted brain-dead and pediatric donation, but LDLT remains predominant. Japan's achievements, supported by advancements in tacrolimus immunosuppression, ABO-incompatible LT, and laparoscopic donor hepatectomy, have produced national survival rates comparable to leading Western programs. To date, over 4000 pediatric liver transplants have been performed, establishing Japan as a global leader in pediatric LDLT. Through sustained educational missions, National Center for Child Health and Development and its partner institutions have supported program development in over 20 countries, particularly in Southeast Asia and the Middle East. Despite limited experience with pediatric deceased-donor transplantation, Japan's balanced pursuit of donor safety, ethical integrity, and innovation continues to shape the international landscape. This personal viewpoint reflects on Japan's 60-year journey-progress born from limitation-and its ongoing commitment to advancing pediatric transplantation worldwide under the vision of the International Pediatric Transplant Association.
Kasahara et al. (Sun,) studied this question.