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The Milan criteria are a set of clinical guidelines developed to assess the eligibility of patients with hepatocellular carcinoma (HCC) for liver transplantation, functioning as a crucial tool in decision-making processes for this specific treatment option. Defined by a strict framework, the criteria aim to identify patients with a limited extent of disease who are most likely to benefit from transplantation while minimizing the risk of post-transplant tumor recurrence. According to the Milan criteria, patients must meet specific conditions: they should have a single tumor with a maximum diameter of 5 centimeters, or up to three tumors, none of which exceeds 3 centimeters in diameter, and there should be no macrovascular invasion or extrahepatic spread of the disease. The Milan criteria emerged from a landmark study conducted in the early 1990s, which demonstrated that liver transplantation offered superior outcomes for selected patients with HCC compared to other forms of treatment. By adhering to these criteria, transplant centers can more effectively allocate limited donor organs to those patients who are most likely to experience long-term survival benefits, thus optimizing overall transplant outcomes. However, compliance with the Milan criteria can sometimes be challenging, as the progression of HCC can lead to rapid changes in tumor burden, necessitating careful monitoring and timely intervention. In recent years, the applicability of the Milan criteria has been further explored, with debates surrounding the potential for expansion to include patients with more advanced disease characteristics, such as those with previously unresectable tumors that have become downsized following pre-transplant therapies like transarterial chemoembolization (TACE) or radiofrequency ablation. Modifications to the criteria have been suggested, leading to the development of alternative scoring systems and models aimed at refining patient selection and increasing access to liver transplantation for HCC patients. These include the Up-to-7 criterion, which allows a combination of tumor size and number that equates to a total score of up to seven when the number of tumors and their sizes are factored together, addressing concerns that the strict definitions of the Milan criteria may exclude some patients who ultimately could benefit from transplantation. Nonetheless, the traditional Milan criteria remain a widely accepted standard in many transplant programs across the globe. As the landscape of HCC management continues to evolve with advancements in therapeutic options and a deeper understanding of tumor biology, ongoing research efforts strive to optimize liver transplantation pathways, ensuring that the best possible outcomes are achieved for patients battling this challenging and complex disease. In summary, the Milan criteria represent a foundational framework in the management of hepatocellular carcinoma, guiding clinicians in their pursuit of the most effective and judicious use of liver transplantation for eligible patients.