Liver transplantation remains one of the most demanding procedures in surgery—alterations in liver physiology, presence of portal hypertension, coexisting comorbidities, and the variability of donor organ quality all contribute to the complexities of liver transplantation. While the steps of the surgical procedure have been protocolized, the performance of a technically exacting procedure is the foundation of good outcomes. Nevertheless, the availability of advanced technology in the operating room, along with advances in anesthesia management, has helped to mitigate the challenges of a hostile abdomen from whatever the causes are. This chapter describes the considerations and obstacles in each phase of the operative procedure.