Pringle Maneuver Research Articles

Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control.

To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM. 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. 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. 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.

Gut Barrier Disruption Secondary to Radiofrequency-Assisted Liver Parenchyma Resection in a Porcine Model

BackgroundRadiofrequency-assisted liver resection (RF-LR) techniques minimize intraoperative blood loss, while avoiding the Pringle maneuver. Both surgical excision and radiofrequency ablation of liver parenchyma compromise gut barrier function with subsequent bacterial translocation. The present study sought to investigate in a porcine model the impact of two RF-LR techniques on the integrity and inflammatory response of the gut barrier. MethodsTwenty-four pigs were subjected to either (a) partial hepatectomy (PH) employing the “sequential coagulate-cut” technique using a monopolar electrode (SCC group), the one using the bipolar Habib-4X device (group H), or the “crush-clamp” technique (group CC) or (b) sham operation (group Sham). At 48-h post-operation, ileal tissue was excised to be subjected to histopathologic examination, histomorphometric analysis, and immunohistochemical assessment of the mitotic and apoptotic activities and the expression of interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and nuclear factor-κB (NFκΒ). ResultsHistopathologic score increased in all PH groups, being higher in group SCC, while lower in group H. Villous height decreased in group SCC only. Mitotic index decreased, while apoptotic index increased in all PH groups. An increase in tissue expression score was noted for IL-6 in group CC, for TNFα in all PH groups, being lower in group H compared to group CC, and for NFκB in all PH groups. ConclusionsThe Habib-4X technique for liver resection proved to preserve the integrity of gut barrier, being less injurious in the intestinal mucosa compared to the SCC and CC techniques.

Does ALT Correlate with Survival After Liver Resection for Colorectal Liver Metastases?

The pringle manoeuvre is commonly used during hepatectomy, which may cause ischaemia-reperfusion injuryand transient liver dysfunction. Post-operative liver transaminases are often used to assess ischaemia-reperfusion injury, although there is conflicting evidence on survival outcomes. The primary aim was to assess post-operative alanine aminotransferase (ALT) with survival outcomes. Secondary aims were to assess ALT level with the length of stay and overall complications. Post-operative day 2 ALT levels of five times the upper limit of normal (i.e. 280 U/L) were considered as clinically significant transaminitis. Kaplan-Meier survival curves were studied using log-rank analysis to identify the predictors of overall survival (OS) and recurrence-free survival (RFS). Out of 752 patients who underwent hepatectomy, 527 (70.1%) patients had low ALT (<280 U/L) and 225 (29.9%) patients had high ALT on day 2 post-op. Post-operative ALT did not affect OS (P=0.883) or RFS (P=0.063). Factors associated with a worse OS and RFS on multivariate analysis were pre-operative chemotherapy, number of tumours and largest tumour size (>4cm). A high post-operative ALT was not associated with the increased length of stay or more complications. Post-operative ALT does not affect survival outcomes post-hepatectomy for colorectal liver metastases.

Pentadecapeptide BPC 157 Anti‐Ulcer Effect After Stomach Perforation also Opposed the Intracranial Hypertension (Superior Sagittal Sinus), Portal and Caval Hypertension and Aortal Hypotension

We report that rat stomach perforation (surgery with 5‐mm diameter metal needle on the ventral side in the prepyloric area) induced a defect that would not heal. Also, stomach perforation rapidly induced the intracranial hypertension (superior sagittal sinus), portal and caval hypertension and aortal hypotension. Stable gastric pentadecapeptide BPC 157 largely attenuated or eliminated these pressure disturbances. Finally, BPC 157 completely healed stomach defect. Previously, BPC 157 largely attenuated or even eliminated the consequences of Budd‐Chiari syndrome in rats, in particular, portal and caval hypertension and aortal hypotension, and then, huge thrombosis in both veins and arteries, and multiple organ dysfunction syndrome, heart, lung, liver, kidney and gastrointestinal lesions. These beneficial effects may relieve a Virchow's triad situation that may be commonly presented as well as counteracted (i.e.,duodenal venous congestion lesions (World J Gastroenterol 2018), perforated cecum (World J Gastroenterol 2018), bile duct ligation induced liver cirrhosis and portal hypertension (Eur J Pharmacol 2109), Pringle maneuver, ischemia, reperfusion (World J Hepatol 2020), and suprahepatic occlusion of the inferior caval vein (Budd‐Chiari‐syndrome) (World J Gastrointest Pathophysiol 2020)). Likewise, given in reperfusion, after clamping of the common carotid arteries, BPC 157 counteracted stroke (i.e., both early and delayed neural hippocampal damage, achieving also full functional recovery) (Brain Behav 2020).MethodsTherapy (BPC 157 (10 µg or 10 ng/kg) or saline (5 ml/kg)) was given intragatrically, at 1 min after stomach perforation. At 5 min after stomach perforation, as described before (World J Hepatol 2020), recordings were made in deeply anesthetized rats. Briefly, a cannula (BD Neoflon™ Cannula) was connected to a pressure transducer (78534C MONITOR/ TERMINAL; Hewlett Packard, USA) inserted into the superior sagittal sinus, and portal vein, and inferior vena cava, and abdominal aorta at the level of the bifurcation. We used five minutes recording. For superior sagittal sinus pressure recording, we made a single burr hole in the rostral part of the sagittal suture, above the superior sagittal sinus, and cannulated superior sagittal sinus anterior part by Braun intravenous cannulas, and then, in laparatomized rats, we recorded portal vein, inferior vena cava and abdominal aorta pressure.ResultsWithout therapy, the severely increased intracranial hypertension (10±2 mmHg in superior sagittal sinus), portal (33±4 mmHg) and caval (28±3 mmHg) hypertension and aortal hypotension (59±3 mmHg) occurred rapidly. Both BPC 157 regimens markedly counteracted intracranial hypertension (‐6±2 mmHg in superior sagittal sinus), portal (6±2 mmHg) and caval (5±2 mmHg) hypertension and aortal hypotension (81±3 mmHg) (i.e., 10 ng).ConclusionBPC 157 anti‐ulcer effect also opposed the intracranial hypertension (superior sagittal sinus), portal and caval hypertension and aortal hypotension.

Bile leak incidence, risk factors and associated outcomes in patients undergoing hepatectomy: a contemporary NSQIP propensity matched analysis.

Despite advances in surgical technique, bile leak remains a common complication following hepatectomy. We sought to identify incidence of, risk factors for, and outcomes associated with biliary leak. This is an ACS-NSQIP study. Distribution of bile leak stratified by surgical approach and hepatectomy type were identified. Univariate and multivariate factors associated with bile leak and outcomes were evaluated. Robotic hepatectomy was associated with less bile leak (5.4% vs. 11.4%; p < 0.001) compared to open. There were no significant differences in bile leak between robotic and laparoscopic hepatectomy (5.4% vs. 5.3%; p = 0.905, respectively). Operative factors risk factors for bile leak in patients undergoing robotic hepatectomy included right hepatectomy [OR 4.42 (95% CI 1.74-11.20); p = 0.002], conversion [OR 4.40 (95% CI 1.39-11.72); p = 0.010], pringle maneuver [OR 3.19 (95% CI 1.03-9.88); p = 0.044], and drain placement [OR 28.25 (95% CI 8.34-95.72); p < 0.001]. Bile leak was associated with increased reoperation (8.7% vs 1.7%, p < 0.001), 30-day readmission (26.6% vs 6.8%, p < 0.001), 30-day mortality (2% vs 0.9%, p < 0.001), and complications (67.2% vs 23.4%, p < 0.001) for patients undergoing MIS hepatectomy. While MIS confers less risk for bile leak than open hepatectomy, risk factors for bile leak in patients undergoing MIS hepatectomy were identified. Bile leaks were associated with multiple additional complications, and the robotic approach had an equal risk for bile leak than laparoscopic in this time period.

A Case-Matched Analysis of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver According to Adaption of Developed Techniques.

Background and Objectives: Laparoscopic liver resection (LLR) for the hepatocellular carcinoma (HCC) located in posterosuperior (PS) segment is technically demanding, but has been overcome by accumulated experiences and technological improvements. We analyzed peri-and post-operative results before and after the adaptation of the enhanced techniques. Materials and Methods: We retrospectively reviewed 246 patients who underwent LLR for HCC in PS segments from September 2003 to December 2019. According to the introduction of advanced techniques including intercostal trocars, Pringle maneuver, and semi-lateral French position, the patients were divided into Group 1 (n = 43), who underwent LLR from September 2003 to December 2011, and Group 2 (n = 203), who underwent LLR from January 2012 to December 2019. Among these cases, 136 patients (Group 1 = 34, Group 2 = 102) were selected by case-matched analysis using perioperative variables. Results: Mean operation time (362 min vs. 291 min) and hospital stay (11 days vs. 8 days, p = 0.023) were significantly longer in Group 1 than Group 2. Otherwise, disease-free survival (DFS) rate was shorter and resection margin (1.3 mm vs. 0.7 mm, p = 0.034) were smaller in Group 2 than Group 1. However, there was no difference in type of complication (p = 0.084), severity of complication graded by the Clavien–Dindo grade system (p = 0.394), and 5-year overall survival (OS) rates (p = 0.986). In case-matched analysis, operation time (359 min vs. 266 min p = 0.002) and hospital stay (11.5 days vs. 8.0 days, p = 0.032) were significantly different, but there was no significant difference in resection margin, DFS, and OS. Conclusions: The adaptation of improved techniques has reduced the complexity of LLR in PS segments.

Is the Pringle manoeuvre becoming a lost art? Contemporary use for both severe liver trauma with ongoing hemorrhage and elective partial hepatectomy

SummaryThe Pringle manoeuvre (vascular inflow occlusion) has been a mainstay technique in trauma surgery and hepato-pancreato-biliary surgery since it was first described in the early 1900s. We sought to determine how frequently the manoeuvre is used today for both elective and emergent cases in these disciplines. To reflect on its evolution, we evaluated the Pringle manoeuvre over a recent 10-year period (2010–2020). We found it is used less frequently owing to more frequent nonoperative management and more advanced elective hepatic resection techniques. Continuing educational collaboration is critical to ensure continued insight into the impact of hepatic vascular inflow occlusion among trainees who observe this procedure less frequently.

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Hepatectomy: A Systematic Review and Meta-Analysis.

ObjectivesMortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion (SHVE) compared to a Pringle maneuver in hepatic resection reduces rates of morbidity and mortality.MethodsA systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and SCOPUS for comparative studies meeting the inclusion criteria. Pooled odds ratios or mean differences were calculated for outcomes using either fixed- or random-effects models.ResultsSix studies were identified: three randomised controlled trials and three observational studies reporting a total of 2,238 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, blood loss, transfusion requirements, air embolism, liver failure and multi-organ failure in the SHVE group. Rates of hepatic vein rupture, post-operative hemorrhage, operative and warm ischemia time, length of stay in hospital and intensive care unit were not statistically significant between the two groups.ConclusionPerforming SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle maneuver. The results of this meta-analysis are based on studies where tumors were adjacent to major vessels. Further RCTs are required to validate these results.Clinical Trial RegistrationPROSPERO (CRD42020212372) https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=212372.

Comment on: "Perioperative and oncological outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution study".

Comment on: “Perioperative and oncological outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution study”

Outcomes of Pure Laparoscopic Living Donor Right Hepatectomy at a Small-Volume Center.

Laparoscopic liver donor surgery is a technically difficult and demanding procedure. Our aim was toevaluate its feasibility at an established transplant center. Although our hospital is a small-volume center with <20 liver transplants per year, laparoscopic donor surgery has been performed regularly. In this study, we have reported our experiences with laparoscopic donor right hepa-tectomy and its outcomes. Between May 2014 and March 2021, 26 deceased donor liver transplants and 37 living donor liver transplants, approved by the Korean Network for Organ Sharing, were performed at out center. From these, we reviewed the medical records, including clinical and demographic characteristics and operative outcomes, of 3 living donors who under-went pure laparoscopic donor right hepatectomy and their recipients. Each of the 3 laparoscopic donor right hepatectomies took over 10 hours with the prolonged Pringle maneuver time and warm ischemic time. However, there were no significant events during surgery or critical postoperative complications. In the recipients, posttransplant complications included middle hepatic vein obstruction, postoperative bleeding, bile leak, septic shock, and primary nonfunction of the graft. We managed and resolved these complications using various approaches, including retransplant, and all 3 recipients recovered and survived. Laparoscopic donor right hepatectomy had a relatively long operative time at our small-volume center. We believe that successful laparoscopic donor hepatectomy is possible if the donor is selected appropriately according to the center's experiences and there are constant efforts to overcome the learning curve.

Robotic Central Bisectionectomy for Centrally Located Hepatic Malignant Tumor.

Laparoscopic hepatectomies for centrally located tumors are classified as advanced and complex surgical procedures.1-3 Because of some limitations in robotic liver surgery,4,5 robotic central bisectionectomy has rarely been performed.6,7 We introduce useful tips for robotic central bisectionectomy in this multimedia article. A 67-year-old male with a 4.4-cm-sized, hepatocellular carcinoma involving segments IV and VIII underwent robotic central bisectionectomy. This video demonstrates technique of determination of resection line,3 traction methods,8 effective use of robotic instruments for parenchymal transection, application of Pringle's maneuver, and indocyanine-green fluorescence image in robotic central bisectionectomy. Total operative time was 320 min and intraoperative blood loss was 200 ml without transfusion. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day in good condition. Pathological assessment indicated that the mass was a hepatocellular carcinoma 4.5 cm in size with a surgical margin of 1.5 cm. Central bisectionectomy is one of the most demanding surgical procedures with long operative times. However, robotic central bisectionectomy can be safely performed with proper exposure technique and an appropriate combination of several useful technical tips.

Increasing incidence and severity of post-hepatectomy adhesion around the liver may be influenced by the hepatectomy-related operative procedures

BackgroundThe incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear. MethodsFirst hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies. ResultsThe incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy. ConclusionHepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Laparoscopic Left Hemihepatectomy for Intrahepatic Cholangiocellular Carcinoma: An Adequate Lymphadenectomy is Also Possible in Artery Variation

BackgroundLaparoscopic liver resection (LLR) is becoming essential in the treatment of malignant liver tumors but only a few reports exist about LLR for intrahepatic cholangiocarcinoma (IHCC).MethodsWe present a video of a laparoscopic left hemihepatectomy with lymphadenectomy for IHCC.Case presentationA 67-year-old asymptomatic male underwent a routine abdominal ultrasound, revealing a 15 × 9 mm solid nodular iso-hyperechoic lesion, located in SIII, with SII/III biliary duct dilation. Magnetic resonance imaging confirmed a 32 × 22 mm lesion in SII/III, with mild hyper-intensity on T2-weighted images and strong hypo-intensity on T1-weighted images. After administration of contrast medium, the lesion showed light peripheral enhancement on the portal and delayed phases, and hypo-intensity on the hepatospecific phase. No relevant comorbidities were reported (KPS 100). Laboratory tests showed normal liver function and normal CA19-9 levels. A laparoscopic left hemihepatectomy was indicated.ResultsOperative time was 330 min. Four intermittent Pringle maneuver cycles were applied and no blood transfusions were administered. Intraoperative ultrasound confirmed preoperative findings and additionally highlighted involvement of the SIV duct. A full replacing right hepatic artery arising from the superior mesenteric artery was identified and was preserved during hilar dissection. Postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology report indicated cholangiocellular carcinoma pT1bN0. Twelve lymph nodes were retrieved.ConclusionsAccording to recent literature reports and our experience, laparoscopic surgery for intrahepatic cholangiocellular carcinoma should be considered feasible and safe in selected patients. Hepatic artery variations allow for adequate lymphadenectomy. Oncological long-term results require multicenter randomized studies in order to be validated.

Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.

Laparoscopic liver resections have been performed with increasing frequency in recent years. With increasing surgical experience and technological developments, more complex laparoscopic liver resections can now be applied. Laparoscopic right posterior sectionectomy (LSPS) requires a sophisticated and highly challenging surgical technique due to the length of the parenchyma transection line and the camera out of view in laparoscopic surgery. The aim of this study was to share tips and tricks about resection which will contribute to the operation time and technique. Evaluation was made of the laparoscopic major liver resections performed consecutively between 2015-2020 in our center. During the resections, three different inflow control techniques were used; hilar, glassonian and intraparenchymal approach. A total of 14 LSPS surgeries were performed. Mean age of the patients was 51.6 ± 10.2 years (34-68), and mean operation time was 300 ± 58 (200-440) minutes. The Pringle maneuver was applied to all patients, with a mean time of 58.4 ± 14.4 (30-75) minutes. Mean perioperative bleeding was measured as 290 ± 105 (140-550) mL. Additional surgery was performed on six patients in the same session. Complications occurred in three patients. No perioperative mortality was observed. LSPS is a technically difficult process, which requires advanced skills in both liver surgery and laparoscopic surgery. Surgeons should consider applying this method, which offers different advantages depending on the location and nature of the lesion, after completing the learning curve by performing laparoscopic liver surgery of the correct number and type. In our article, we stated the tips and tricks that make it easy to perform laparoscopic right posterior sectionectomies, which have been thought to be difficult until recently and these difficulties have been clearly stated in many articles.

An example of “pancreatic Pringle maneuver” during a distal pancreatectomy with venous resection

An example of “pancreatic Pringle maneuver” during a distal pancreatectomy with venous resection

The Evaluation of the 1318 nm Diode Laser in Open Liver Surgery.

Simple SummaryThe surgical treatment of liver metastases but also of primary liver tumors is of particular clinical relevance in view of their high incidence. As a therapy option with a prospect of long-term survival in curative intent, liver resection plays a crucial role in modern multimodal treatment concepts. Advances in surgical and perioperative medicine have led to a reduction of procedural mortality to less than 5% and morbidity to around 35–45% and have rendered liver resections from high risk to routine procedures. Several comparisons of common parenchymal dissection techniques showed no specific advantages in favor of one of the methods in terms of morbidity, mortality and intraoperative blood loss. The aim of our retrospective study was to evaluate the 1318 nm diode pumped neodymium-yttrium aluminum garnet laser in open liver surgery. It could be shown that liver resections using the 1318 nm surgical laser can be carried out with an acceptable risk and are equally safe compared to conventional resection methods with comparatively little blood loss and favorable oncological surrogate outcomes.(1) Background: Numerous dissection instruments are available for liver resection. So far, there has been no evidence in favor of a specific dissection device effecting a reduction in postoperative mortality and morbidity or a reduction in intraoperative blood loss. The aim of the study was to evaluate the safety of liver resection with the 1318 nm surgical laser. (2) Methods: 151 consecutive patients who underwent liver resection using the 1318 nm surgical laser (n = 119) or conventional dissection methods (n = 32) were evaluated retrospectively. As primary outcome, postoperative complications were assessed using the Clavien–Dindo classification. Secondary outcomes were postoperative mortality, reoperations and reinterventions, intraoperative blood loss, the need for vascular control using the Pringle maneuver and oncological safety assessed through histopathological evaluation of resection margins. (3) Results: For liver resections using the 1318 nm surgical laser, the postoperative morbidity (41.2% vs. 59.4%, p = 0.066), mortality (1.7% vs. 3.1%, p = 0.513) and the reoperation rate (2.5% vs. 3.1%, p = 1.000) were not significantly different from conventional liver resections. In the laser group, a lower reintervention rate (9.2% vs. 21.9%, p = 0.050) was observed. The oncological safety demonstrated by a tumor-free resection margin was similar after laser and conventional resection (93.2% vs. 89.3%, p = 0.256). The median intraoperative blood loss was significantly lower in the laser group (300 mL vs. 500 mL, p = 0.005) and there was a significantly lower need for a Pringle maneuver (3.4% vs. 15.6%, p = 0.021). (4) Conclusions: Liver resections using the 1318 nm surgical laser can be routinely performed with a favorable risk profile. Compared to alternative resection methods, they are associated with low blood loss, appear adequate from an oncological point of view, and are not associated with increased mortality and morbidity.

Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy

Jehovah’s Witness patients presenting for liver surgery pose challenges to the anesthetists as well as the surgeons, due to their abstinence from receiving blood products. Despite this, surgery is the only curative option for operable colorectal liver metastases (CRLM). We report a case of a Jehovah’s Witness with multiple comorbidities who had a parenchyma sparing hepatectomy (PSH) complicated by intraoperative bleeding. A 52-year-old ASA II patient with hypertension, diabetes and ischemic heart disease on dual antiplatelet therapy was scheduled for open PSH for multiple bilobar CRLMs. He was prehabilitated with an emphasis on enhancing erythropoiesis and improving his functional capacity. PSH was done using a Cavitron ultrasonic surgical aspirator (CUSA) with intermittent Pringle maneuver, a low central venous pressure and restricted intravenous fluids. His postoperative recovery was complicated by a minor upper gastrointestinal bleed that was managed conservatively.&#x0D; The authors certify that informed written consent has been obtained from patient for publication.&#x0D; Keywords: Jehovah’s Witness; Liver surgery; Anesthesia; Hepatectomy&#x0D; Citation: Dassanayake V, Sivaganesh S, Subasinghe D, Pitigala P. Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy. Anaesth. pain intensive care 2021;26(1):119–122 ;&#x0D; DOI: 10.35975/apic.v26i1.1787&#x0D; Received: October 16, 2021, Reviewed: October 28, 2021, Accepted: November 07, 2021

Perioperative and oncologic outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution experience.

Scarce data are available regarding the technique and outcomes for patients with RCC and Mayo III caval thrombi. The aim of this study was to report surgical and oncological outcomes of RCC patients with Mayo III thrombi treated with radical nephrectomy and thrombectomy after liver mobilization (LM) and Pringle maneuver (PM). Retrospective analysis of surgical technique, outcomes and cancer control in 19 patients undergoing LM and PM in a single tertiary care institution were analyzed. Overall, 78% of the patients had performance status ECOG 1 and 58% had a Comorbidity Index >2. Median surgical time was 305 minutes (IQR 264-440). Intraoperative complications were reported for 39% of patients and postoperative complications for 58% (only grade 1 and 2). Intensive Care Unit support was necessary in 16% of the cases. Median length of hospital stay was 9 days (IQR: 7-11). Thirty- and 90-day mortality were 5% and 15%. Two-year overall survival and cancer-specific survival were 60% and 62%, respectively. We reported surgical techniques, intra- and perioperative complications and follow-up in the largest cohort of RCC patients requiring LM and PM.

V03 - Robotic Pringle maneuver and suprahepatic IVC control for level 3b IVC thrombi

V03 - Robotic Pringle maneuver and suprahepatic IVC control for level 3b IVC thrombi

Dissecting aneurysm of the proper hepatic artery after laparoscopic hepatectomy possibly related to the Pringle maneuver: A case report

In hepatectomy, the Pringle maneuver is commonly used, but its association with iatrogenic injury is not yet well understood. This report presents a case of dissecting aneurysm of the proper hepatic artery (PHA) possibly associated with the Pringle maneuver during laparoscopic hepatectomy, that was successfully treated by transcatheter arterial embolization (TAE). The patient was a woman in her 70s, and repeat hepatectomy for liver metastasis of rectal neuroendocrine neoplasm was planned. She underwent hand-assisted laparoscopic hepatectomy with the Pringle maneuver. On postoperative day (POD) 7, enhanced computed tomography showed a dissecting aneurysm of the PHA. TAE of the PHA to prevent hemorrhage was performed on POD 9 with no complications. Even after TAE, intrahepatic arterial flow was provided by the peribiliary arteries. This case suggests the possibility that the Pringle maneuver can cause a dissecting aneurysm of the hepatic artery.