Overview
Definition:
The Pringle maneuver is a surgical technique involving the temporary occlusion of hepatic inflow by clamping the portal triad (porta hepatis)
This reduces blood flow into the liver, thereby controlling hemorrhage from liver parenchyma or major hepatic vessels during surgery.
Purpose:
Its primary purpose is to provide a bloodless field for hepatectomy, control life-threatening intraoperative bleeding from the liver, and reduce blood loss during trauma surgery
It also facilitates dissection of the hepatic hilum.
Historical Context:
First described by J
H
Pringle in 1908, the maneuver has been a cornerstone in managing hepatic bleeding and enabling complex liver resections for over a century.
Indications
Major Hepatic Resections:
Essential for all elective major hepatectomies (e.g., trisegmentectomy, lobectomy) to minimize blood loss and improve visualization.
Liver Trauma:
Indicated in cases of severe hepatic trauma with active bleeding that cannot be controlled by other means.
Emergency Situations:
Used in emergent settings for intraoperative hemorrhage from the liver, such as rupture of a hepatocellular carcinoma or hemangioma.
Portal Hypertension Surgery:
May be employed during complex procedures for portal hypertension to manage variceal bleeding or during shunting procedures.
Contraindications
Absolute Contraindications:
Rarely, patients with severe coagulopathy unresponsive to correction or those with known significant hepatic outflow obstruction may have contraindications, but these are generally relative.
Relative Contraindications:
Prolonged occlusion times can lead to ischemia
therefore, the duration of the maneuver is a critical consideration
Patients with pre-existing severe hepatic dysfunction may tolerate occlusion poorly.
Technique
Surgical Approach:
Typically performed through a standard laparotomy or laparoscopic approach
The surgeon gains access to the porta hepatis.
Porta Hepatis Dissection:
Careful dissection around the portal triad is crucial
The structures within the portal triad are the portal vein, hepatic artery, and common hepatic duct
The key is to isolate the portal vein and hepatic artery.
Occlusion Method:
A non-crushing vascular clamp or a sterile umbilical tape/Penrose drain is passed around the hepatoduodenal ligament and tightened to occlude both the portal vein and hepatic artery
Care must be taken to avoid injuring the common bile duct or hepatic veins.
Duration And Monitoring:
The maneuver is typically maintained for 15-20 minutes, followed by a 5-minute release to allow reperfusion and assess bleeding
This cycle is repeated as needed
Continuous monitoring of hepatic function (e.g., transaminases) and clinical signs of ischemia is important.
Complications
Ischemia Reperfusion Injury:
Prolonged or repeated occlusion can lead to ischemic hepatitis and potential organ dysfunction.
Bile Duct Injury:
Accidental injury to the common hepatic duct or bile radicles during dissection or clamping.
Hemorrhage:
Inadequate clamping or premature release can lead to uncontrolled bleeding.
Postoperative Liver Failure:
In susceptible individuals, especially after extensive resections, prolonged ischemia can contribute to liver failure.
Thrombosis:
Rarely, thrombosis of the portal vein or hepatic artery can occur.
Alternatives And Adjuncts
Selective Inflow Occlusion:
In some cases, selective occlusion of individual vessels (e.g., only portal vein) might be considered.
Total Vascular Exclusion:
A more aggressive technique involving occlusion of suprahepatic and infrahepatic IVC in addition to hepatic inflow, used for complex hilar tumors or vascular resections.
Intraoperative Ultrasound:
Essential for identifying vascular structures and assessing tumor margins.
Key Points
Exam Focus:
The Pringle maneuver is a critical testable topic for DNB and NEET SS Surgery
Focus on indications, contraindications, precise technique, potential complications, and strategies for safe application.
Clinical Pearls:
Always perform careful dissection of the porta hepatis
Use intermittent clamping to minimize ischemia
Monitor liver function closely
Have blood products readily available
Laparoscopic Pringle requires meticulous technique and specialized instruments.
Common Mistakes:
Clamping the wrong structures, prolonged, uninterrupted occlusion, failing to reperfuse, and inadequate follow-up of liver function postoperatively are common pitfalls to avoid.