Ann Hepatobiliary Pancreat Surg.  2023 May;27(2):131-140. 10.14701/ahbps.22-109.

The Pringle maneuver in the modern era: A review of techniques for hepatic inflow occlusion in minimally invasive liver resection

• Mownah OA
• Aroori S

• KMID: 2542576
• DOI: http://doi.org/10.14701/ahbps.22-109

Abstract

During minimally invasive liver resection (MILR), the Pringle maneuver aims to minimize blood loss and provide a clear operative field, thereby identifying intrahepatic structures and facilitating safe parenchymal transection. Several techniques for using the Pringle maneuver in MILR have been described. This review presents various methods which have been reported in the literature. A systematic literature search used the MEDLINE/PubMed database from its earliest records to August 2022 using appropriate search headings and keywords. The primary outcome was identifying techniques for performing hepatic inflow occlusion during laparoscopic/robotic hepatectomy. Inclusion criteria consisted of publications describing technical steps to obtain hepatic inflow occlusion during minimally invasive hepatectomy. A literature search identified 23 relevant publications, and the full texts were examined. The techniques described in the reports can be broadly categorized into three groups: (1) the Rummel-tourniquet technique, (2) vascular clamp use, and (3) the Huang Loop technique. Various techniques have been used in MILR to achieve inflow confinement successfully. The authors prefer the modified Huang Loop technique because it is inexpensive, reliable, and quick to apply or release. Hepatobiliary surgeons are advised to familiarize themselves with these MILR techniques, which have proven effective and safe inflow occlusion.

Keyword

Hepatectomy; Minimally invasive surgical procedures; Laparoscopy; Robotic surgical procedures

Figure

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  Fig. 1 PRISMA diagram of study inclusion.

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  Fig. 2 Rummel tourniquet technique.

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  Fig. 3 The Bulldog technique.

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  Fig. 4 The Huang Loop technique.

Reference

1. Haney CM, Studier-Fischer A, Probst P, Fan C, Müller PC, Golriz M, et al. 2021; A systematic review and meta-analysis of randomized controlled trials comparing laparoscopic and open liver resection. HPB (Oxford). 23:1467–1481. DOI: 10.1016/j.hpb.2021.03.006. PMID: 33820689.

2. Kamarajah SK, Bundred J, Manas D, Jiao L, Hilal MA, White SA. 2021; Robotic versus conventional laparoscopic liver resections: a systematic review and meta-analysis. Scand J Surg. 110:290–300. DOI: 10.1177/1457496920925637. PMID: 32762406.

3. Tsilimigras DI, Moris D, Vagios S, Merath K, Pawlik TM. 2018; Safety and oncologic outcomes of robotic liver resections: a systematic review. J Surg Oncol. 117:1517–1530. DOI: 10.1002/jso.25018. PMID: 29473968.

4. Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. 1996; Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg. 224:155–161. DOI: 10.1097/00000658-199608000-00007. PMID: 8757378. PMCID: PMC1235336.

5. Pringle JH. 1908; V. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 48:541–549. DOI: 10.1097/00000658-190810000-00005. PMID: 17862242. PMCID: PMC1406963.

6. Okuda Y, Honda G, Kurata M, Kobayashi S. 2013; Useful and convenient procedure for intermittent vascular occlusion in laparoscopic hepatectomy. Asian J Endosc Surg. 6:100–103. DOI: 10.1111/ases.12003. PMID: 23126444.

7. Onda S, Haruki K, Furukawa K, Yasuda J, Shirai Y, Sakamoto T, et al. 2021; Newly-revised Pringle maneuver using laparoscopic Satinsky vascular clamp for repeat laparoscopic hepatectomy. Surg Endosc. 35:5375–5380. DOI: 10.1007/s00464-021-08516-9. PMID: 33913029.

8. Huang JW, Su WL, Wang SN. 2018; Alternative laparoscopic intracorporeal Pringle maneuver by Huang's loop. World J Surg. 42:3312–3315. DOI: 10.1007/s00268-018-4584-z. PMID: 29589115.

9. Cai J, Zheng J, Xie Y, Kirih MA, Jiang G, Liang Y, et al. 2020; A novel simple intra-corporeal Pringle maneuver for laparoscopic hemihepatectomy: how we do it. Surg Endosc. 34:2807–2813. DOI: 10.1007/s00464-020-07513-8. PMID: 32206920.

10. Belli G, Fantini C, D'Agostino A, Cioffi L, Limongelli P, Russo G, et al. 2008; Laparoscopic segment VI liver resection using a left lateral decubitus position: a personal modified technique. J Gastrointest Surg. 12:2221–2226. DOI: 10.1007/s11605-008-0537-4. PMID: 18473147.

11. Zhang C, Yu J, Ma J. 2021; How to perform laparoscopic intracorporeal Pringle manoeuvre: Zhang's modified method. ANZ J Surg. 91:742–743. DOI: 10.1111/ans.16710. PMID: 33665920.

12. SteinbrÜck K, Fernandes R, D'Oliveira M, Capelli R, Cano R, Vasconcelos H, et al. 2021; External pringle maneuver in laparoscopic liver resection: a safe, cheap and reproducible way to perform it. Arq Bras Cir Dig. 33:e1555. DOI: 10.1590/0102-672020200004e1555. PMID: 33503115. PMCID: PMC7836078.

13. Gao Z, Li Z, Zhou B, Chen L, Shen Z, Jiang Y, et al. 2021; A self-designed liver circle for on-demand Pringle's manoeuver in laparoscopic liver resection. J Minim Access Surg. 17:120–126. DOI: 10.4103/jmas.JMAS_130_19. PMID: 33353898. PMCID: PMC7945630.

14. Choi YI. 2020; The usefulness of the totally intra-corporeal pringle maneuver with Penrose drain tube during laparoscopic left side liver resection. Ann Hepatobiliary Pancreat Surg. 24:252–258. DOI: 10.14701/ahbps.2020.24.3.252. PMID: 32843589. PMCID: PMC7452809.

15. Peng Y, Wang Z, Wang X, Chen F, Zhou J, Fan J, et al. 2019; A novel very simple laparoscopic hepatic inflow occlusion apparatus for laparoscopic liver surgery. Surg Endosc. 33:145–152. DOI: 10.1007/s00464-018-6285-y. PMID: 29943053.

16. Lim C, Osseis M, Lahat E, Azoulay D, Salloum C. 2018; Extracorporeal Pringle maneuver during laparoscopic and robotic hepatectomy: detailed technique and first comparison with intracorporeal maneuver. J Am Coll Surg. 226:e19–e25. DOI: 10.1016/j.jamcollsurg.2018.02.003. PMID: 29501783.

17. Laurenzi A, Cherqui D, Figueroa R, Adam R, Vibert E, Sa Cunha A. 2018; Totally intra-corporeal Pringle maneuver during laparoscopic liver resection. HPB (Oxford). 20:128–131. DOI: 10.1016/j.hpb.2017.05.013. PMID: 29239841.

18. Piardi T, Lhuaire M, Memeo R, Pessaux P, Kianmanesh R, Sommacale D. 2016; Laparoscopic Pringle maneuver: how we do it? Hepatobiliary Surg Nutr. 5:345–349. DOI: 10.21037/hbsn.2015.11.01. PMID: 27500146. PMCID: PMC4960419.

19. Mizuguchi T, Kawamoto M, Nakamura Y, Meguro M, Hui TT, Hirata K. 2015; New technique of extracorporeal hepatic inflow control for pure laparoscopic liver resection. Surg Laparosc Endosc Percutan Tech. 25:e16–e20. DOI: 10.1097/SLE.0b013e3182a4c0f4. PMID: 25533749.

20. Nomi T, Fuks D, Agrawal A, Govindasamy M, Araki K, Gayet B. 2015; Modified Pringle maneuver for laparoscopic liver resection. Ann Surg Oncol. 22:852. DOI: 10.1245/s10434-014-4088-5. PMID: 25223928.

21. Dua MM, Worhunsky DJ, Hwa K, Poultsides GA, Norton JA, Visser BC. 2015; Extracorporeal Pringle for laparoscopic liver resection. Surg Endosc. 29:1348–1355. DOI: 10.1007/s00464-014-3801-6. PMID: 25159645.

22. Chao YJ, Wang CJ, Shan YS. 2012; Technical notes: a self-designed, simple, secure, and safe six-loop intracorporeal Pringle's maneuver for laparoscopic liver resection. Surg Endosc. 26:2681–2686. DOI: 10.1007/s00464-012-2210-y. PMID: 22437948.

23. Rotellar F, Pardo F, Bueno A, Martí-Cruchaga P, Zozaya G. 2012; Extracorporeal tourniquet method for intermittent hepatic pedicle clamping during laparoscopic liver surgery: an easy, cheap, and effective technique. Langenbecks Arch Surg. 397:481–485. DOI: 10.1007/s00423-011-0887-3. PMID: 22183106.

24. Patriti A, Ceccarelli G, Bartoli A, Casciola L. 2011; Extracorporeal Pringle maneuver in robot-assisted liver surgery. Surg Laparosc Endosc Percutan Tech. 21:e242–e244. DOI: 10.1097/SLE.0b013e31822d7fb4. PMID: 22002285.

25. Herman P, Perini MV, Coelho F, Saad W, D'Albuquerque LA. 2010; Half-Pringle maneuver: a useful tool in laparoscopic liver resection. J Laparoendosc Adv Surg Tech A. 20:35–37. DOI: 10.1089/lap.2009.0215. PMID: 20059322.

26. Cho A, Yamamoto H, Nagata M, Takiguchi N, Shimada H, Kainuma O, et al. 2009; Safe and feasible inflow occlusion in laparoscopic liver resection. Surg Endosc. 23:906–908. DOI: 10.1007/s00464-008-0257-6. PMID: 19116742.

27. Belli G, Fantini C, D'Agostino A, Belli A, Langella S. 2005; Laparoscopic hepatic resection for completely exophytic hepatocellular carcinoma on cirrhosis. J Hepatobiliary Pancreat Surg. 12:488–493. DOI: 10.1007/s00534-005-1006-z. PMID: 16365825.

28. Kurokawa T, Inagaki H, Sakamoto J, Nonami T. 2002; Hand-assisted laparoscopic anatomical left lobectomy using hemihepatic vascular control technique. Surg Endosc. 16:1637–1638. DOI: 10.1007/s00464-002-4212-7. PMID: 12085137.

29. Nomi T, Fuks D, Kawaguchi Y, Mal F, Nakajima Y, Gayet B. 2015; Learning curve for laparoscopic major hepatectomy. Br J Surg. 102:796–804. DOI: 10.1002/bjs.9798. PMID: 25873161.

30. Lyu X, Qiao W, Li D, Leng Y. 2017; Impact of perioperative blood transfusion on clinical outcomes in patients with colorectal liver metastasis after hepatectomy: a meta-analysis. Oncotarget. 8:41740–41748. DOI: 10.18632/oncotarget.16771. PMID: 28410243. PMCID: PMC5522331.

31. Martin AN, Kerwin MJ, Turrentine FE, Bauer TW, Adams RB, Stukenborg GJ, et al. 2016; Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy. J Surg Res. 206:106–112. DOI: 10.1016/j.jss.2016.07.013. PMID: 27916348. PMCID: PMC5142215.

32. He L, Li W, Zhou D, Wang L, Hou H, Geng X. 2021; Comparative analysis of vascular bulldog clamps used in laparoscopic liver resection. Medicine (Baltimore). 100:e26074. DOI: 10.1097/MD.0000000000026074. PMID: 34114991. PMCID: PMC8202581.