Safety of prolonged intermittent pringle maneuver during hepatic resection

It has recently been demonstrated that the liver parenchyma is more tolerant to intermittent pedicular clamping than to continuous pedicular clamping. However, the possibility of increased blood loss during intermittent reperfusion is a major concern.

We retrospectively selected 34 cases in which the cumulative clamping time was 90 minutes or longer during hepatectomy and the intermittent Pringle maneuver was applied rather than continuous inflow occlusion.

Resections were performed for metastatic carcinoma in 19 patients, hepatocellular carcinoma in 7 patients, hilar bile duct carcinoma in 3 patients, intrahepatic cholangiocarcinoma in 1 patient, combined hepatocellular carcinoma and cholangiocarcinoma in 1 patient, undifferentiated embryonal sarcoma in 1 patient, carcinoid tumor in 1 patient, and benign mucinous cystic tumor in 1 patient. Patients were categorized on the basis of the cumulative clamping time, with 25 patients in group 1 (< or =120 minutes) and 9 patients in group 2 (>120 minutes). In 2 patients in group 2, the cumulative clamping time exceeded 240 minutes. Twenty-eight patients had histologically normal underlying liver parenchyma; 6 patients had chronic hepatitis or cirrhosis.

No red blood cell transfusions were required in group 1; blood transfusions were needed for only 3 patients in group 2. There was no postoperative mortality or major complications. The rate of minor postoperative complications was 36% (9 patients) in group 1 and 22% (2 patients) in group 2.

Prolonged intermittent pedicular clamping is a useful maneuver in hepatectomy when resection is difficult or prolonged or when the liver parenchyma is abnormal. Such clamping can be used for cumulative periods exceeding 120 minutes without major intraoperative blood loss or complications.