title: Extracorporeal Pringle for laparoscopic liver resection.
abstract: BACKGROUND
  A primary concern during laparoscopic liver resection (lapLR) is hemorrhage during parenchymal transection. Intermittent pedicle clamping is an effective method to minimize blood loss during open liver surgery; however, inflow occlusion techniques are challenging to reproduce during laparoscopy. The purpose of this study is to describe the safety and efficacy of a facile method for Pringle maneuver during lapLR.
  
  
  METHODS
  154 patients who underwent lapLR from 2007 to 2013 were retrospectively reviewed. For Pringle, the hepatoduodenal ligament is encircled with an umbilical tape which is externalized through a flexible Rumel tourniquet running alongside a port used for the operation. The internal end of the catheter is close to the pedicle and the external end is extracorporeal, allowing for easy external occlusion. Patients who underwent Pringle Maneuver (PM, n = 88) were compared to patients who had "No Occlusion" (NO, n = 66) with respect to patient characteristics, operative outcomes, changes in postoperative liver function, and complications.
  
  
  RESULTS
  Annual placement of the tourniquet and vascular occlusion increased from 35.7 to 82.8 % (p = 0.004) and 21.4 to 62.1 % (p = 0.02), respectively. Median occlusion time was 24 min (IQR 15-34.3, min 5, max 70). Peak transaminase levels were comparable between groups (AST 298 ± 32 vs 405 ± 47 U/L, p = 0.15; ALT 272 ± 27 vs 372 ± 34 U/L, p = 0.14, NO and PM, respectively). Postoperative transaminase and bilirubin levels for both groups were not significantly different with similar recovery to baseline. Subgroup analysis of cirrhotic patients who underwent Pringle demonstrated similar transaminase profiles compared to non-cirrhotic patients. There were two conversions (1.3 %) and postoperative 30-day mortality was 0.65 %.
  
  
  CONCLUSIONS
  Extracorporeal tourniquet placement in lapLR is a quick and safe method of gaining control for inflow occlusion. Routine adoption of laparoscopic Pringle maneuver facilitates low conversion rates without liver injury.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3691, Stanford, CA, 94305, USA, mdua@stanford.edu.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.forename: David J
authors.initials: DJ
authors.lastname: Worhunsky
authors.forename: Kimberly
authors.initials: K
authors.lastname: Hwa
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D000368:Aged; D003250:Constriction; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008111:Liver Function Tests; D008113:Liver Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D014111:Tourniquets / Q000009:adverse effects*