Related Experiment Video
Updated: Aug 24, 2026
Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver
Published on: June 16, 2023
Pringle's maneuver and selective inflow occlusion in living donor liver hepatectomy
Hiroshi Imamura1, Norihiko Kokudo, Yasuhiko Sugawara
1Division of Hepatobiliary-Pancreatic Surgery and Artificial Organ and Transplantation Surgery, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. himamura-tky@umin.ac.jp
Insights
Selective intermittent inflow occlusion, including Pringle's maneuver, can be safely used during living donor hepatectomy. This technique reduces donor bleeding risk without compromising graft quality in living donor liver transplantation.
Area of Science:
- Hepatobiliary Surgery
- Transplant Surgery
- Surgical Innovation
Background:
- Inflow occlusion, like Pringle's maneuver, is standard in liver surgery to minimize bleeding.
- Donor hepatectomy for living donor liver transplantation (LDLT) traditionally avoids inflow occlusion due to graft injury concerns.
Purpose of the Study:
- To evaluate the safety and efficacy of selective intermittent inflow occlusion during donor hepatectomy in LDLT.
- To assess the impact of inflow occlusion techniques on graft quality and recipient outcomes.
Main Methods:
- A retrospective review of donor hepatectomy cases using selective intermittent inflow occlusion and Pringle's maneuver from November 2000 onwards.
- Graft quality assessment based on maximum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in recipients.
Main Results:
- No primary graft nonfunction or dysfunction was observed in any recipient.
- Recipient AST levels were comparable across groups with varying degrees of ischemia (total, partial, portal, or no ischemia).
- Maximum ALT levels were slightly lower in the total ischemia group, though not statistically significant.
Conclusions:
- Total inflow occlusion is a safe technique for living donor hepatectomy, posing no significant risk of graft injury.
- Applying inflow occlusion techniques enhances donor safety by providing a blood-free transection surface.
- Surgeons should consider adopting inflow occlusion in LDLT donor hepatectomy to improve donor safety.
Abstract:
While inflow occlusion techniques such as Pringle's maneuver are accepted methods of reducing bleeding without inducing liver injury during liver surgery, donor hepatectomy for living donor liver transplantation is currently performed without inflow occlusion for fear that injury to the graft may result. We have performed donor hepatectomy for 12 years using selective intermittent inflow occlusion, a technique in which the portion used to form the graft is perfused during hepatectomy. Starting in November 2000, we applied intermittent Pringle's maneuver to donor hepatectomy in 81 cases of living donor liver transplantation. We reviewed our experience with Pringle's maneuver and selective inflow occlusion techniques in donor hepatectomy in living donor liver transplantation. The quality of the grafts was assessed and compared by determining maximum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values. Neither primary nonfunction nor dysfunction occurred. Maximum AST values in the recipients were the same whether the liver segments that formed the grafts were totally ischemic during dissection (total ischemia), partially ischemic (partial ischemia), perfused only with arterial blood flow (portal ischemia), or not ischemic at all (no ischemia). Maximum ALT values in the recipients of the total ischemia group was lower, albeit not significantly, than in other groups. Total inflow occlusion can be applied to living donor hepatectomy without causing graft injury. In conclusion, because the transection surface is blood-free, there is decreased risk to the donor during living donor liver transplantation surgery, and surgeons should not hesitate to apply this technique because it contributes to donor safety.
