Technical notes: a self-designed, simple, secure, and safe six-loop intracorporeal Pringle's maneuver for laparoscopic liver resection

"Hooking method" for hepatic inflow control: a new approach for laparoscopic Pringle maneuver

BACKGROUND

The laparoscopic Pringle maneuver is crucial for controlling bleeding during laparoscopic hepatectomy. In this study, we introduce a new laparoscopic Pringle maneuver and preliminarily investigate its application in laparoscopic hepatectomy.

METHODS

We collected and analyzed the clinical data of 17 consecutive patients who underwent laparoscopic hepatectomy at the Department of Hepatic Surgery, the First Affiliated Hospital of the University of Science and Technology of China, from January 2022 to January 2023. All patients underwent the hooking method for intermittent occlusion of hepatic inflow. Intraoperative and postoperative clinical indices were observed and recorded.

RESULTS

All 17 patients underwent laparoscopic hepatectomy with hepatic inflow control using the hooking method. Four patients with adhesions under the hepatoduodenal ligament successfully had occlusion loops placed using the hooking method combined with Zhang's modified method during surgery. The median occlusion time for the 17 patients was 34 (12-60) min, and the mean operation time was 210 ± 70 min. The mean intraoperative blood loss was 145 ± 86 ml, and no patients required intraoperative blood transfusion. The patients' postoperative peak AST was 336 ± 183 U/L, and the postoperative peak ALT was 289 ± 159 U/L. Postoperative complications occurred in 2 patients (11.8%), including 1 Clavien-Dindo grade I and 1 Clavien-Dindo grade II complication. No Clavien-Dindo grade IIIa or higher complications or deaths occurred in any patient. None of the patients developed portal vein thrombosis or hepatic artery aneurysm formation. The median postoperative hospital stay was 6 (4-14) days.

CONCLUSION

The hooking method combines the advantages of both intracorporeal Pringle maneuver and extracorporeal Pringle maneuver. It is a simple, safe, and effective method for controlling hepatic inflow and represents a promising approach for performing totally intracorporeal laparoscopic Pringle maneuver.

Indocyanine green fluorescence-guided laparoscopic hepatectomy versus conventional laparoscopic hepatectomy for hepatocellular carcinoma: A single-center propensity score matching study

Background

Indocyanine green fluorescence-guided laparoscopic hepatectomy (ICG-guided LH) is increasingly used for the treatment of hepatocellular carcinoma (HCC). However, whether ICG-guided LH can improve surgical outcomes remains unclear. This study aimed to investigate the short-term outcomes and survival outcomes of ICG-guided LH versus common laparoscopic hepatectomy (CLH) for HCC.

Methods

We conducted a retrospective analysis of 104 ICG-guided LH and 158 CLH patients from 2014 to 2020 at our center. To avoid selection bias, 81 ICG-guided LH and 81 CLH cases were analyzed after 1:1 propensity score matching (PSM). The baseline data and results were compared between the two groups.

Results

The baseline characteristics of both groups were comparable after matching. There was a significant difference in operative time: longer in the ICG-guided LH group than in the CLH group (p=0.004). However, there was no significant difference in operative time in anatomical resection between the two groups (p=0.987). There was a significant difference in operative time in non-anatomical resection: longer in the ICG-guided LH group than in the CLH group (p=0.001). There were no significant differences in positive surgery margin, blood loss, blood transfusion rate, postoperative complication rate, postoperative length of hospital stay, mortality within 30 days, and mortality within 90 days. The ICG-guided LH group appeared to have a trend towards better overall survival (OS), but there was no significant difference in OS (P=0.168) and recurrence-free survival (RFS) (P=0.322) between the two groups.

Conclusions

Although ICG fluorescence-guided LH is a timelier procedure to perform, it is a safe and effective technique with the advantages of intraoperative positioning, low postoperative complication rates, and potential to improve OS.

A self-designed liver circle for on-demand Pringle's manoeuver in laparoscopic liver resection

BACKGROUND

Laparoscopic liver resection (LLR) allows minimal incisions and relatively quicker post-operative recovery, while intraoperative massive haemorrhage led to conversion to laparotomy. This study aimed to introduce a new, safe and convenient device to serve as Pringle's manoeuver according to the demand in LLR.

METHODS

A liver circle consisting of a hole and a round stem with an obtuse small head was made by medical silica gel. It was applied in LLR to perform on-demand Pringle's manoeuver and developed its function in inferior vena cava (IVC) occlusion. The time of performing Pringle's manoeuver by liver circle, extracorporeal tourniquet and endo intestinal clip under laparoscopic simulator and LLR was compared.

RESULTS

The liver circle was successfully applied to perform Pringle's manoeuver, IVC exposure and occlusion. It took less time in the occluding step of Pringle's manoeuver than the extracorporeal tourniquet (4.15 ± 0.35 s vs. 9.90 ± 1.15 s, P < 0.05) and the endo intestinal clip (4.15 ± 0.35 s vs. 47.91 ± 3.98 s, P < 0.05) under LLR. The total manipulating time for Pringle's manoeuver with liver circle remained the shortest, and the advantages were more obvious with increased frequencies of intermittent Pringle's manoeuver.

CONCLUSION

The new-designed liver circle is more convenient compared to other techniques in performing Pringle's manoeuver, especially the intermittent Pringle's manoeuver in LLR. It can be used to perform on-demand hepatic blood inflow occlusion in every LLR by pre-circling the hepatoduodenal ligament to control bleeding during surgery. It can also be applied to expose the surgical field of vision and perform IVC occlusion to reduce intraoperative blood loss.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BACKGROUND

Few studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis.

METHODS

Patients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed.

RESULTS

Among patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching.

CONCLUSIONS

In patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

Laparoscopic Pringle maneuver: how we do it?

Laparoscopic liver resection (LLR) is technically possible with new devices which allow a relatively bloodless liver parenchymal transection. Despite, the main concern remains intraoperative hemorrhage. Currently, perioperative excessive blood loss during LLR is difficult to control with necessity of laparotomy conversion. Moreover, major blood loss requires transfusion and increases postoperative morbidity and mortality. When in-flow is limited by the hepatic pedicle clamping, it reduces intraoperative blood loss. The Pringle maneuver, first described in 1908, is the simplest method of inflow occlusion and currently can be achieved during LLR. The purpose of this note was to describe two different modalities of Pringle maneuver used by two different teams during LLR.

Appraisal of Laparoscopic Liver Resection in the Treatment of Liver Metastasis with Special Reference to Outcome in Colorectal Malignancies

Treatment of metastatic liver disease is at the crossroads of an evolutionary transformation with more and more reports reiterating the benefits of resectional therapy in various cancers. A quest for application of laparoscopic approaches to the management of liver metastasis has arisen due to the projected benefits of less morbidity, early recovery, and equivalent oncological outcome in selected malignancies. However, the diverse and heterogenous data on indications, operative technique, and outcome evaluation make a comparative analysis of these studies difficult. This review is an appraisal of technique and outcome of minimally invasive liver resection as reported in the current literature with special reference to treatment of metastatic colorectal cancers.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

[Laparoscopic liver surgery]

Liver resection remains the method of choice for curative treatment for liver tumors. Development in diagnostic and surgical techniques has improved operative results as well as long-term outcomes. In the last decade minimally invasive laparoscopic (LAP) surgery has been increasingly adopted by liver units. The trend in LAP liver resection has been moving from limited resections towards major hepatectomy. This process, however, is relatively slow, which can be due to technical difficulties of the procedure and fear of haemorrhage. Despite having a hard time at the start, major resections become more common. Up to now approximately 6000 LAP liver resections were performed worldwide, number of major hepatectomies is estimated between 700-800. LAP liver resections are feasible with significant benefits for patients consisting of less blood loss, less narcotic requirements, and shorter hospital stay with comparable postoperative morbidity and mortality to open liver resections. It is an accepted management of both benign and malignant liver lesions. There is no difference between LAP and open surgery in late survival after resection for colorectal liver metastases. Overall survival of LAP resected hepatocellular carcinoma cases seems to be superior compared with open surgery.