Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control
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Published on: June 16, 2023
Shinichiro Nakada1,2, Yuichiro Otsuka3, Jun Ishii1
1Division of General and Gastroenterological Surgery, Department of Surgery, Toho University Faculty of Medicine, 6-11-1, Omorinishi, Otaku, Tokyo, 143-8541, Japan.
Purpose:
To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM.
Methods:
Data from patients undergoing LLR between 2013 and 2020 were reviewed retrospectively. Univariate and multivariate analyses were performed and the outcomes of patients who underwent PM or alternative procedures were compared.
Results:
Among 106 patients who underwent LLR, PM could not be performed in 18 (17.0%) because of abdominal adhesions in 14 (77.8%) and/or collateral flow around the hepatoduodenal ligament in 5 (27.8%). Multivariate analysis revealed that Child-Pugh classification B (p = 0.034) and previous liver resection (p < 0.001) were independently associated with difficulty in performing PM in LLR. We evaluated pre-coagulation of liver tissue using microwave tissue coagulators, saline irrigation monopolar, clamping of the hepatoduodenal ligament using an intestinal clip, and hand-assisted laparoscopic surgery as alternatives procedures to PM. There were no significant differences in blood loss (p = 0.391) or transfusion (p = 0.518) between the PM and alternative procedures.
Conclusions:
Child-Pugh classification B and previous liver resection were identified as predictors of a difficult PM in LLR. The alternative procedures were found to be effective.
Insights
Predictors of a difficult Pringle maneuver (PM) during laparoscopic liver resection (LLR) include Child-Pugh B classification and prior liver surgery. Alternative methods to PM proved effective, with no significant differences in blood loss or transfusion rates.
Area of Science:
- Hepatobiliary surgery
- Minimally invasive surgery
- Surgical oncology
Background:
- The Pringle maneuver (PM) is crucial for controlling intraoperative bleeding during laparoscopic liver resection (LLR).
- Predicting and managing difficulties with PM is essential for patient safety and surgical outcomes.
- Abdominal adhesions and collateral flow can impede PM execution.
Purpose of the Study:
- To identify predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR).
- To evaluate the efficacy of alternative procedures when PM cannot be performed.
Main Methods:
- Retrospective review of 106 patients undergoing LLR between 2013 and 2020.
- Univariate and multivariate analyses to determine predictors of difficult PM.
- Comparison of outcomes between patients undergoing PM and alternative procedures.
Main Results:
- PM was not feasible in 17.0% of cases due to adhesions and/or collateral flow.
- Child-Pugh B classification and previous liver resection were independent predictors of difficult PM (p<0.05).
- Alternative procedures, including microwave tissue coagulators and hand-assisted surgery, showed no significant difference in blood loss or transfusion requirements compared to PM.
Conclusions:
- Child-Pugh B classification and prior liver resection are key predictors of difficulty performing the Pringle maneuver during LLR.
- Alternative methods for hemostasis are effective and safe when PM is challenging.
- These findings aid in surgical planning and risk assessment for LLR.
