Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Liver Resections: Prospective Study

Abstract

Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.

Surgical approaches of resectable synchronous colorectal liver metastases: Timing considerations

“…Liver transection was conducted by the clamp crushing technique with Kelly clamp or by the sharp liver transection technique. Details of the liver transection have been described elsewhere [10,23] . The factors analyzed to compare the two surgical strategies were: intraoperative blood loss, transfusion requirements to keep hematocrit above 29%, postoperative complications, hospital stay, 30-day mortality rate and cumulative survival.…”

“…Bleeding during hepatectomy is a poor prognostic factor and all efforts should be centered at minimizing blood loss by meticulous techniques and liver vascular control [1][2][3]10,23] . It appears that application of the Pringle maneuver in an intermittent manner should be preferred because it causes less liver reperfusion injury and intestinal edema, which might compromise the safety of gut anastomoses [4,10,21] .…”

Does clamping during liver surgery predispose to thrombosis of the hepatic veins? Analysis of 210 cases

“…Hemostasis was achieved by suturing all vascular orifices on the cut surface with 3-0 and 4-0 prolene. After completion of the liver resection, outflow was released first, followed by liver inflow [5,6] . Following reperfusion, hemostasis was completed using additional stitches.…”

“…SHVE entails disconnection of the liver from the retrohepatic IVC and inflow occlusion combined with extrahepatic control of hepatic veins. This technique offers bloodless liver transection without the abovementioned disadvantages of PM and THVE [5,6] . Dissection and clamping of the hepatic veins during the application of SHVE may predispose the major hepatic veins to thrombi formation through the induction of venous stasis and endothelial injury coupled with coagulation disturbances.…”

Techniques for Liver Resection

“…The other concern is the ischaemic-reperfusion injury to the liver parenchyma, especially in patients with underlying liver diseases 20 . The continuous Pringle manoeuvre (CPM) can be safely applied to the normal liver under normothermic conditions for up to 60 minutes and up to 30 minutes in pathological (fatty or cirrhotic) livers, although much longer durations of continuous clamping 127 minutes in normal livers and 100 minutes in pathological livers have been reported to be safe [21][22][23][24] . One way to extend the duration of clamping and to reduce ischaemia to the remnant liver is by the intermittent Pringle manoeuvre (IPM).…”