The Pringle manoeuvre (also spelled “Pringle maneuver”) is a surgical technique used to control hemorrhage from the liver by temporarily occluding the hepatic inflow. The method involves clamping the hepatoduodenal ligament, which contains the portal vein, hepatic artery, and bile duct (the portal triad), thereby reducing blood flow to the liver and limiting intra‑operative bleeding.
Historical background
- Named after the Australian surgeon Sir James Hogarth Pringle (1863–1941).
- First described in 1908 in his article “The Control of Bleeding in Hepatic Surgery” published in The British Journal of Surgery.
Procedure
- After a laparotomy exposing the liver, the surgeon isolates the hepatoduodenal ligament.
- A vascular clamp, tourniquet, or thick suture is applied around the ligament to compress the portal triad.
- The clamp is usually applied intermittently (e.g., 15‑20 minutes clamped, 5‑10 minutes released) to reduce the risk of ischemic injury to the liver.
- Once the source of bleeding is addressed (e.g., resection, repair, or coagulation), the clamp is released.
Indications
- Major hepatic resections (e.g., lobectomy, segmentectomy).
- Trauma to the liver with uncontrolled bleeding.
- Cases where the source of intra‑hepatic bleeding cannot be identified promptly.
Benefits
- Provides a rapid, technically simple means of reducing blood loss.
- Facilitates a clearer operative field, allowing precise surgical dissection.
Risks and complications
- Hepatic ischemia leading to temporary or permanent liver dysfunction, especially if the occlusion exceeds 60‑90 minutes.
- Biliary stasis or cholestasis due to interruption of bile flow.
- Potential injury to the portal triad structures if the clamp is placed incorrectly.
Variations and related techniques
- Selective hepatic inflow occlusion: Clamping only the portal vein or hepatic artery rather than the entire triad.
- Total hepatic vascular exclusion (THVE): Combined occlusion of both inflow (Pringle) and outflow (hepatic veins and inferior vena cava) for complex resections.
- Intra‑operative ultrasound may be used to guide safe placement of the clamp.
Clinical relevance
The Pringle manoeuvre remains a cornerstone of hepatic surgery and trauma management. Modern liver resections often employ intermittent clamping to balance hemostasis with preservation of hepatic function. Ongoing research evaluates optimal clamp duration, protective pharmacologic agents, and the role of pre‑conditioning to mitigate ischemia–reperfusion injury.
References
- Pringle J.H. “The Control of Bleeding in Hepatic Surgery.” British Journal of Surgery, 1908.
- Makuuchi M, et al. “Surgical Management of Liver Tumors.” Annals of Surgery, 2006.
- Haeju J, et al. “Ischemic Preconditioning and the Pringle Maneuver in Liver Resection.” Journal of Hepatobiliary Surgery, 2019.
