Technical Description of a Non-Assisted Intracorporeal Pringle Maneuver for Robotic Liver Resection

Minimally invasive hepatectomy has been steadily becoming more available for liver resections globally. Techniques used in open hepatectomy do not often translate directly to minimally invasive surgery (MIS), one example being control of blood supply to the liver during surgery. In open repairs, the Pringle Maneuver has been widely adopted; however, during MIS, clamping of the hepatoduodenal ligament is challenging, as exemplified in recent literature reviews. Techniques that have emerged from laparoscopic MIS have typically required extracorporeal manipulation or intracorporeal clipping, requiring coordination between the surgical assistant and the primary surgeon. A method to manage blood flow intracorporeally by the primary surgeon during robotic surgery is of major interest. Here, we present a technique that utilizes a readily available instrument, the red rubber intermittent urinary catheter, to control hepatic blood flow during robotic liver resection. Cutting the flanged end of the catheter provides a self-securing mechanism that can be actioned by the surgeon intracorporeally. In our experience, this securing mechanism provides adequate halt of the inflow of blood to the liver, and the tourniquet does not slip, allowing the primary surgeon control of tourniquet release timing. This technique allows the primary surgeon to apply and release the tourniquet as needed, without the need for a surgical assistant, additional incisions, or increased major expense.