Pringle manoeuvre | |
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Specialty | General surgery |
Uses | Liver surgery |
Complications | Increased blood loss in patients with chronic venous insufficiency |
Approach | Open surgery. Compress hepatoduodenal ligament |
The Pringle manoeuvre is a surgical technique used in some abdominal operations and in liver trauma. The hepatoduodenal ligament is clamped either with a surgical tool called a haemostat, an umbilical tape or by hand. This limits blood inflow through the hepatic artery and the portal vein, controlling bleeding from the liver. It was first published by and named after James Hogarth Pringle in 1908.
The Pringle manoeuvre is used during liver surgery and in some cases of severe liver trauma to minimize blood loss. [1] For short durations of use, it is very effective at reducing intraoperative blood loss. [2] The Pringle manoeuvre is applied during closure of a vena cava injury when an atriocaval shunt is placed.[ citation needed ]
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 manoeuver technique aims at controlling the blood inflow into the liver, having no effect on the outflow. [3] In case of using Pringle manoeuver during liver trauma, should bleeding continue, it is likely that the inferior vena cava or the hepatic vein are also traumatised. [4] If bleeding continues, a variation in arterial blood flow may be present.
The Pringle manoeuvre can directly lead to reperfusion injury in the liver, causing impaired function. [5] This is particularly true for long durations of use, such as more than 120 minutes of intermittent Pringle occlusion. [6]
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:
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. [8]
The inferior vena cava is a large vein that carries the deoxygenated blood from the lower and middle body into the right atrium of the heart. It is formed by the joining of the right and the left common iliac veins, usually at the level of the fifth lumbar vertebra.
Liver tumors are abnormal growth of liver cells on or in the liver. Several distinct types of tumors can develop in the liver because the liver is made up of various cell types. Liver tumors can be classified as benign (non-cancerous) or malignant (cancerous) growths. They may be discovered on medical imaging, and the diagnosis is often confirmed with liver biopsy. Signs and symptoms of liver masses vary from being asymptomatic to patients presenting with an abdominal mass, hepatomegaly, abdominal pain, jaundice, or some other liver dysfunction. Treatment varies and is highly specific to the type of liver tumor.
Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.
A Klatskin tumor is a cholangiocarcinoma occurring at the confluence of the right and left hepatic bile ducts. The disease was named after Gerald Klatskin, who in 1965 described 15 cases and found some characteristics for this type of cholangiocarcinoma
Cholangiocarcinoma, also known as bile duct cancer, is a type of cancer that forms in the bile ducts. Symptoms of cholangiocarcinoma may include abdominal pain, yellowish skin, weight loss, generalized itching, and fever. Light colored stool or dark urine may also occur. Other biliary tract cancers include gallbladder cancer and cancer of the ampulla of Vater.
A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.
In anatomy, the gastroduodenal artery is a small blood vessel in the abdomen. It supplies blood directly to the pylorus and proximal part of the duodenum. It also indirectly supplies the pancreatic head.
Hepatectomy is the surgical resection of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on partial resections of hepatic tissue and hepatoportoenterostomy.
James Hogarth Pringle was an Australian-born British surgeon in Glasgow, who made a number of important contributions to surgical practice. He is most famous for the development of the Pringle manoeuvre, a technique still used in surgery today.
Haemobilia is a medical condition of bleeding into the biliary tree. Haemobilia occurs when there is a fistula between a vessel of the splanchnic circulation and the intrahepatic or extrahepatic biliary system. It can present as acute upper gastrointestinal (UGI) bleeding. It should be considered in upper abdominal pain presenting with UGI bleeding especially when there is a history of liver injury or instrumentation.
Hepatic arterial infusion (HAI) is a medical procedure that delivers chemotherapy directly to the liver. The procedure, mostly used in combination with systemic chemotherapy, plays a role in the treatment of liver metastases in patients with colorectal cancer (CRC). Although surgical resection remains the standard of care for these liver metastases, majority of patients have lesions that are unresectable.
A liver metastasis is a malignant tumor in the liver that has spread from another organ affected by cancer. The liver is a common site for metastatic disease because of its rich, dual blood supply. Metastatic tumors in the liver are 20 times more common than primary tumors. In 50% of all cases the primary tumor is of the gastrointestinal tract; other common sites include the breast, ovaries, bronchus and kidney. Patients with Colorectal cancer will develop liver metastases during the disease
In oncology, metastasectomy is the surgical removal of metastases, which are secondary cancerous growths that have spread from cancer originating in another organ in the body.
Perihepatic packing is a surgical procedure used in connection with trauma surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.
An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.
A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.
An atriocaval shunt (ACS) is an intraoperative surgical shunt between the atrium of the heart and the inferior vena cava. It is used during the repair of larger juxtahepatic vascular injuries such as an injury to the local vena cava. Injuries to the inferior vena cava are challenging, those behind the liver being the most difficult to repair.
Alexey Nikolaevich Severtsev – a Russian doctor of medicine sciences, professor in the hospital surgery department of the medical faculty in Pirogov Russian National Research Medical University and the chief surgeon of a chain of clinics “MEDSI”.
Portal vein embolization (PVE) is a preoperative procedure performed in interventional radiology to initiate hypertrophy of the anticipated future liver remnant a couple weeks prior to a major liver resection procedure. The procedure involves injecting the right or left portal vein with embolic material to occlude portal blood flow. By occluding the blood flow to areas of the liver that will be resected away, the blood is diverted to healthy parts of the liver and induces hyperplasia. This may allow for a more extensive resection or stage bilateral resections that would otherwise be contraindicated resulting in better oncological treatment outcomes.
Radiation lobectomy is a form of radiation therapy used in interventional radiology to treat liver cancer. It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with yttrium-90 into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from portal vein embolization (PVE).