The Pringle manoeuvre is a

surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

technique used in some

abdominal The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso ...

operation Operation or Operations may refer to: Arts, entertainment and media * ''Operation'' (game), a battery-operated board game that challenges dexterity * Operation (music), a term used in musical set theory * ''Operations'' (magazine), Multi-Ma ...

s and in liver trauma. The

hepatoduodenal ligament The hepatoduodenal ligament is the portion of the lesser omentum extending between the porta hepatis of the liver and the superior part of the duodenum. Running inside it are the following structures collectively known as the portal triad: * hep ...

is clamped either with a surgical tool called a haemostat, an umbilical tape or by hand. This limits blood inflow through the

hepatic artery The common hepatic artery is a short blood vessel that supplies oxygenated blood to the liver, pylorus of the stomach, duodenum, pancreas, and gallbladder. It arises from the celiac artery and has the following branches: Additional images ...

and the portal vein, controlling bleeding from the

liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...

Uses

The Pringle manoeuvre is used during liver surgery and in some cases of severe liver trauma to minimize blood loss. For short durations of use, it is very effective at reducing intraoperative

blood loss Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...

. The Pringle manoeuvre is applied during closure of a vena cava injury when an atriocaval shunt is placed.

Limits

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. In case of using Pringle manoeuver during liver trauma, should bleeding continue, it is likely that the

inferior vena cava 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 th ...

or the

hepatic vein In human anatomy, the hepatic veins are the veins that drain venous blood from the liver into the inferior vena cava (as opposed to the hepatic portal vein which conveys blood from the gastrointestinal organs to the liver). There are usually thre ...

are also traumatised. If bleeding continues, a variation in arterial blood flow may be present.

Adverse effects

The Pringle manoeuvre can directly lead to

reperfusion injury Reperfusion injury, sometimes called ischemia-reperfusion injury (IRI) or reoxygenation injury, is the tissue damage caused when blood supply returns to tissue ('' re-'' + ''perfusion'') after a period of ischemia or lack of oxygen (anoxia or hy ...

in the liver, causing impaired function. This is particularly true for long durations of use, such as more than 120 minutes of intermittent Pringle occlusion.

Technique

The Pringle manoeuvre consists in clamping the

(the free border of the

lesser omentum The lesser omentum (small omentum or gastrohepatic omentum) is the double layer of peritoneum that extends from the liver to the lesser curvature of the stomach, and to the first part of the duodenum. The lesser omentum is usually divided into th ...

). This interrupts the flow of

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...

through the

and the portal vein, which helps to control bleeding from the

. The common bile duct is also temporarily closed during this procedure. This can be achieved using: * a large atraumatic

hemostat A hemostat (also called a hemostatic clamp, arterial forceps, or pean after Jules-Émile Péan) is a surgical tool used in many surgical procedures to control bleeding. For this reason, it is common in the initial phases of surgery for the initia ...

(soft clamp). * manual compression. * vessel loop or umbilical tape.

History

The Pringle manoeuvre was developed by

James Hogarth Pringle James Hogarth Pringle (born 26 January 1863 in Parramatta, Australia – died 24 April 1941 in Killearn, Scotland) was an Australian-born British surgeon in Glasgow, who made a number of important contributions to surgical practice. He is most f ...

in the early 1900s in order to attempt to control bleeding during severe liver traumatic injuries. He was a graduate of medicine at the

University of Edinburgh Medical School The University of Edinburgh Medical School (also known as Edinburgh Medical School) is the medical school of the University of Edinburgh in Scotland and the United Kingdom and part of the University of Edinburgh College of Medicine and Veterinar ...

References

{{Digestive system procedures Hepatology