Pringle Maneuver 

Updated: Jun 10, 2020
Author: Todd A Nickloes, DO, FACOS; Chief Editor: Vincent Lopez Rowe, MD 

Overview

Background

In 1908, Pringle first described a technique to minimize blood loss during hepatic surgery by clamping the vascular pedicle (now commonly known as the Pringle maneuver).[1]  The inflow of blood to the liver is via the hepatic artery and portal vein (see the image below). Surgeons must be able to isolate and control these sources of blood flow to control bleeding not only in traumatic injuries to the liver but also in elective hepatic resections.

Liver anatomy. Liver anatomy.

Clamping of the hepatic pedicle allows surgeons to evaluate traumatic liver injury. It does so by allowing one to determine if the hemorrhage is from branches of the hepatic artery or the portal vein. When a clamp is applied to the pedicle, hemorrhage ceases if it is from either of these sources. If hemorrhage continues, the other likely sources of bleeding include the retrohepatic vena cava and hepatic veins.[2]

Indications

Traumatic injury to the liver can result in massive hemorrhage. Intraoperative blood loss is a major determinant of perioperative outcome.[3] Temporary control of hemorrhage is important in terms of buying time while the anesthesiologist restores the circulating volume before further blood loss occurs. It also allows time for repair of other injuries that may be of higher priority without unnecessary blood loss.[2] Once patients are stabilized, they may be taken back to the operating room for definitive procedures.

The Pringle maneuver is one technique that enables surgeons to halt hemorrhage and find the source of bleeding, allowing time for repair of the vessel. In the setting of hepatic resection of benign and malignant lesions, this maneuver can be used to assist with control of bleeding.[4, 5] However, total vascular occlusion is more appropriate for hepatic resection.[6]

Ongoing bleeding may be controlled by this maneuver. If hemorrhage continues after this technique, hepatic bypass is an option. However, it may be more appropriate to perform damage-control laparotomy and tightly pack the liver.[7] This will allow for continued resuscitation and stabilization. The surgeon may return at a later time to reexplore and perform definitive repair.

Inferior vena cava (IVC) injuries can be lethal and difficult to isolate and repair. If the IVC is actively bleeding, exploration is warranted. When the right hemiliver is mobilized, an active rush of blood indicates an injury to the right or left hepatic vein. If there is a large retroperitoneal hematoma, then a retrohepatic vena cava injury is likely.

The liver should be packed and a sternotomy performed. The intrapericardial portion of the IVC can be controlled with a Rumel tourniquet (Heaney technique). This, along with the Pringle maneuver, allows time for the surgeon to repair the injured vessel.[8]

Selective inflow occlusion is not required for living donor hepatectomy. Total inflow occlusion using the Pringle maneuver can be performed without causing graft injury.[9] A study by Takatsuki et al found that whereas the Pringle maneuver could be safely performed in living donor hepatectomy, the only benefit was reduced blood loss during the donor surgery; they noted no significant positive impact on outcome for the recipient.[10]

A 2012 British trial comparing the efficacy of the Pringle maneuver combined with a low initial volume status (P+LCVP) to the Pringle maneuver with infrahepatic IVC clamping (P+IVCC) in complex liver resections demonstrated superiority of P+IVCC in decreasing blood loss, improving time to return of liver function, and decreasing the degree of renal dysfunction.[11]

The Pringle manuver has also been suggested as potentially useful for controlling bleeding and thereby helping to reduce the conversion rate in difficult laparoscopic cholecystectomies. A study by Zhao et al found it to be feasible and safe in this setting.[12]

Contraindications

No absolute contraindications for this procedure exist. For patients with impaired liver function, such as those with cirrhosis, clamping time until ischemia and portal hypertension is significantly reduced. In such instances, intermittent clamping for increments of 10 minutes at a time should be performed.[3]

 

Periprocedural Care

Equipment

An atraumatic vascular clamp, such as a Satinski or curved Debakey clamp, can be used for placement across the portal triad to occlude the inflow. Ligation equipment or an electrocautery may be useful for opening the lesser sac/omentum.

Patient Preparation

A general anesthetic and an abdominal laparotomy are the norm, though this maneuver is amenable to laparoscopic application. Open abdominal exploration is most appropriate for abdominal trauma. However, elective liver surgery may be performed via laparotomy or laparoscopy.

The patient should be kept in the supine position.

Monitoring & Follow-up

Postoperative aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels are not routinely measured after trauma-related surgery. However, after liver resection and living donor hepatectomy, these values may be followed to ensure recovery of liver function.[9]

 

Technique

Clamping of Hepatic Pedicle

In the setting of trauma, when a surgeon enters the abdomen and is faced with significant hemorrhage, this maneuver should be used expeditiously. If a nasogastric tube is not already in position, it should be placed while exposure is obtained so as to decompress the stomach. The left lateral section of the liver, which includes segments II and III, should then be elevated. This allows visualization of the caudate lobe.

Division of the lesser omentum through the avascular plane between the caudate lobe/falciform junction of the liver and the lesser curvature of the stomach may then be accomplished. The foramen of Winslow may then be accessed by placing a finger directly on the caudate lobe and sweeping it to the right, thereby encircling the hepatoduodenal ligament/porta hepatis through the foramen of Winslow.

An alternative approach after division of the lesser omentum is from the lateral aspect, along the inferior border of the right hemiliver, cephalad to the pylorus, and through the epiploic foramen (of Winslow). An atraumatic vascular clamp should be applied at this location.

The Pringle maneuver is illustrated in the image below.

Pringle maneuver. Pringle maneuver.

Modified forms of the maneuver that use tapes, tubes, or tourniquets have been described for use in laparoscopic and robot-assisted liver resection.[13, 14, 15, 16, 17, 18]

Complications

Ischemia and portal hypertension are complications that result from either prolonged clamping time during the Pringle maneuver or normal clamping time in patients with compromised liver function (eg, from cirrhosis).

To minimize the risk of ischemic injury to the liver parenchyma, especially in patients with already compromised liver function, the surgeon should intermittently clamp and release the portal inflow at 15- to 20-minute intervals. This "warm ischemia" minimizes the time for which the liver is without blood supply, thereby minimizing ischemia.

A prospective pilot study by Donadon et al suggested that giving N-acetylcysteine or methylprednisolone before the Pringle maneuver during liver resection yielded less postoperative aberration in liver function test results than placebo when the maneuver was maintained for longer than 70 minutes.[19] Further studies are required to determine what role pharmacologic modulation of ischemia-reperfusion injury may play when the Pringle maneuver is employed in liver surgery.

A study by Ueda et al evaluated the effectiveness of portal vein flow after the Pringle maneuver and the impact that massaging the hepatoduodenal ligament after the Pringle maneuver had on portal vein flow in 101 patients (divided into a massage group and a nonmassage group).[20] Portal vein flow after the Pringle maneuver was improved after massage of the hepatoduodenal ligament. After hepatectomy, serum prothrombin time was significantly higher and serum C-reactive protein was significantly lower in the massage group than in the nonmassage group.

Total vascular occlusion is accomplished by occluding the portal triad inflow and the infrahepatic and suprahepatic inferior vena cava. Total occlusion is associated with significant hemodynamic instability and spontaneous splenic rupture.[3]