Pringle manoeuvre

Uses

The Pringle manoeuvre is used during liver surgery and in some cases of severe liver trauma to minimise blood loss. For short durations of use, it is very effective at reducing intraoperative blood loss. The Pringle manoeuvre is applied during closure of a vena cava injury when an atriocaval shunt is placed.

Limits

The Pringle manoeuvre is more effective in preventing blood loss during liver surgery if central venous pressure is maintained at 5 mmHg or lower. This is due to the fact that Pringle manoeuvre technique aims at controlling the blood inflow into the liver, having no effect on the outflow. In case of using Pringle manoeuvre during liver trauma, should bleeding continue, it is likely that the inferior vena cava or the hepatic vein are also traumatised. If bleeding continues, a variation in arterial blood flow may be present.

Adverse effects

The Pringle manoeuvre can directly lead to reperfusion injury in the liver, causing impaired function. This is particularly true for long durations of use, such as more than 120 minutes of intermittent Pringle occlusion.

Technique

The Pringle manoeuvre consists in clamping the hepatoduodenal ligament (the free border of the lesser omentum). This interrupts the flow of blood through the hepatic artery and the portal vein, which helps to control bleeding from the liver. The common bile duct is also temporarily closed during this procedure. This can be achieved using:

• a large atraumatic haemostat (soft clamp).
• manual compression.
• vessel loop or umbilical tape.

History

The Pringle manoeuvre was developed by James Hogarth Pringle in the early 1900s in order to attempt to control bleeding during severe liver traumatic injuries.

References

References

1. (2007-01-01). "Chapter 82 - Liver Resection in Cirrhosis of the Liver". W.B. Saunders.
2. (December 1997). "Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.". Annals of Surgery.
3. (2004-03-01). "The role of central venous pressure and type of vascular control in blood loss during major liver resections". The American Journal of Surgery.
4. (16 February 2007). "Master Medicine: Clinical Anatomy".
5. (1999-05-01). "Tolerance of the Liver to Intermittent Pringle Maneuver in Hepatectomy for Liver Tumors". Archives of Surgery.
6. (May 1999). "Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors.". Archives of Surgery.
7. (2017-01-01). "Chapter 103B - Hepatic resection for benign disease and for liver and biliary tumors". Elsevier.
8. (2009-01-01). "Chapter 31 - Right Hepatectomy". W.B. Saunders.