What is the Pringle maneuver?
The Pringle maneuver is a procedure to stop the liver’s blood supply during a liver surgery. A clamp is applied over the hepatic vascular pedicle, the channel that contains the hepatic duct, hepatic artery and the portal vein.
The hepatic artery and the portal vein are the blood vessels that carry blood to the liver. The hepatic artery carries the oxygenated blood to the liver, while the portal vein brings the nutrient rich blood from the digestive tract. The liver processes the blood from the portal vein, absorbs the nutrients and removes the toxic substances.
Pringle maneuver is named after J. Hogarth Pringle who, in 1908, first described the technique to minimize blood loss during a liver surgery. Now it is a standard procedure during any liver surgery. The procedure is performed as an emergency measure in surgeries for abdominal injuries.
Why is Pringle maneuver performed?
The Pringle maneuver is performed to stop the blood inflow into the liver during a surgery. This minimizes blood loss and the resulting need for transfusion.
The Pringle maneuver is performed as a standard part of the procedure in many surgeries such as:
- Traumatic liver injury: The liver is the most commonly injured organ in a trauma to the abdominal region. The Pringle maneuver enables the surgeon to
- Immediately stop further blood loss
- Determine the origin of hemorrhage
- Control the hemorrhage
- Repair injured blood vessels
- Liver resection: removal of a part of the liver, or the whole liver in case of a transplant, in patients with
- Liver cirrhosis
- Liver cancer
- Living donor hepatectomy: removal of a part of the liver for transplant, from a living donor
- Biliary tract reconstruction: reconstruction surgery performed for treatment of bile duct diseases
- Cholecystectomy: removal of gallbladder
How is the Pringle maneuver performed?
The Pringle maneuver is a technique performed during major abdominal surgeries involving the biliary system. The technique may be applied during an open or a laparoscopic surgery. The patient is under general anesthesia during the procedure.
Preparation
Before the surgery, the patient
- Undergoes physical examination, blood, urine and imaging tests.
- Must avoid eating or drink anything for 8 hours prior.
- Must inform the doctor of any allergies.
- Must check with the doctor before taking any regular medications.
Procedure
- The anesthesiologist administers anesthesia and monitors the vital functions during the surgery.
- The surgeon usually inserts a tube through the nose into the stomach to decompress the stomach.
- The surgeon may also insert a urinary catheter to decompress the bladder.
- The surgeon makes one or more incisions in the stomach depending on the type of surgery.
- The surgeon finds the hepatic vascular pedicle, lifts it up and applies the clamp.
- Pringle maneuver may be applied intermittently in 10- to 20-minute cycles, allowing five minutes of blood flow (reperfusion) in between.
- For surgeries of short duration Pringle maneuver may be applied continuously.
- After the surgery is completed, the surgeon removes the clamp and ensures that there is no damage to the vessels and blood flow is normal.
- The surgeon closes the incision with sutures.
Post-procedure
- The patient is brought out of anesthesia.
- The patient will be under observation for several hours in the recovery room.
- Pain medication will be administered for postoperative pain.
- The patient may need hospitalization for a week or more, depending on the type of surgery and underlying condition of the patient.
- The patient’s liver function will be monitored with follow-up tests.
What are the risks and complications of the Pringle maneuver?
Pringle maneuver has greatly reduced the risks involved with liver surgeries due to excessive bleeding. The complications that may arise from Pringle maneuver include:
- Anesthetic side effects such as
- Surgical risks such as
- Wound infection
- Pneumonia
- Bleeding
- Blood clots
- Injury to other organs, blood vessels or nerves
- Reaction to medications
- Damage to the liver due to ischemia (lack of blood supply) leading to liver dysfunction
- Ischemia-reperfusion injury to the liver tissue caused when blood supply returns after a period of ischemia
- Damage to the gallbladder or bile duct
- Portal hypertension -- increase of pressure in the portal vein
- Rupture of spleen
- Bile leakage
- Complications from the associated surgery
- Abnormal or erratic blood pressure
- Sepsis and death
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