Technical Description of a Non-Assisted Intracorporeal Pringle Maneuver for Robotic Liver Resection

Summary

This paper presents an efficient and completely intracorporeal approach to clamping of the hepatoduodenal ligament during robotic liver resection utilizing a single, readily available surgical tool.

Abstract

Minimally invasive hepatectomy has been steadily becoming more available for liver resections globally. Techniques used in open hepatectomy do not often translate directly to minimally invasive surgery (MIS), one example being control of blood supply to the liver during surgery. In open repairs, the Pringle Maneuver has been widely adopted; however, during MIS, clamping of the hepatoduodenal ligament is challenging, as exemplified in recent literature reviews. Techniques that have emerged from laparoscopic MIS have typically required extracorporeal manipulation or intracorporeal clipping, requiring coordination between the surgical assistant and the primary surgeon. A method to manage blood flow intracorporeally by the primary surgeon during robotic surgery is of major interest. Here, we present a technique that utilizes a readily available instrument, the red rubber intermittent urinary catheter, to control hepatic blood flow during robotic liver resection. Cutting the flanged end of the catheter provides a self-securing mechanism that can be actioned by the surgeon intracorporeally. In our experience, this securing mechanism provides adequate halt of the inflow of blood to the liver, and the tourniquet does not slip, allowing the primary surgeon control of tourniquet release timing. This technique allows the primary surgeon to apply and release the tourniquet as needed, without the need for a surgical assistant, additional incisions, or increased major expense.

Introduction

The need for hepatic resection has been steadily increasing with the rise of hepatocellular carcinoma cases globally and metastatic tumors from other sites, accounting for up to 90% of all liver tumors¹. Current treatment options have greatly improved patient outcomes, particularly overall survival; however, when surgery is indicated and completed successfully, there is a lower risk of recurrence.

The field of liver surgery was previously limited to open techniques but has recently been trending towards more minimally invasive approaches with advances in laparoscopy; more recently, the adoption of robotic-assisted surgeries has found influence within hepatic resection. Within the past 10 years, cumulative studies have suggested that minimally invasive liver surgeries (MILS) have increased from ~2% to upwards of ~30%-70% of those being robotic-assisted (within hospitals with developed robotic surgical oncology programs)^2,3.

Hepatic parenchymal vasculature management is one of the most crucial portions of any liver resection, oncologic or otherwise, and heavily impacts patient outcome and other secondary measures of surgical success^4,5. In fact, intraoperative blood loss and need for intraoperative blood transfusion have been shown to be independent predictors of perioperative morbidity and mortality^6,7. Hepatic pedicle clamping (widely known as the Pringle maneuver) was initially used for vascular control during trauma surgery, but quickly became a main step in open hepatic surgery, and is now used in MILS for control of liver vasculature during resection⁸. The maneuver involves en masse clamping of the hepatoduodenal ligament utilizing some form of a vascular tourniquet to induce intra-parenchymal inflow occlusion. In open trauma surgery, this is often performed using the lead surgeon’s thumb and first finger to clamp the vasculature^8,9.

The Pringle maneuver has represented a specific challenge in MILS because of the need for external manipulation. Several techniques have been developed for laparoscopic liver resection (LLR) that are not feasible during robotic liver resection (RLR). While extracorporeal and intracorporeal Pringle techniques have previously been described with adequate control of blood flow, each with specific pros and cons, in robotic surgery, the lead surgeon is not readily available to actuate the tourniquet at the bedside in the event of major hemorrhage or to limit unnecessary ischemic time. This poses a significant risk to the patient, as typically there is either a junior surgeon/resident, or sometimes only a qualified surgical technician coordinating at the bedside, making the intracorporeal technique more desirable^{9,10,11,12,13,14,15}. Previously reported completely intracorporeal Pringle maneuvers in MILS rarely take into account the logistics of robotic surgery, despite RLR now making up a large percentage of MILS^13,14,15. Even as recently as the 2026 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) manual, though both extracorporeal and intracorporeal techniques were described, there was not a specific mention of the robotic Pringle maneuver¹⁶.

The commonly used intracorporeal techniques for laparoscopic resection involve an additional 12 mm port with seemingly blind and blunt entrance of instruments into the pars flaccida to thread either an umbilical tape, a complex encircling system, and use of securing clips, or a Foley catheter through the foramen of Winslow, increasing the chance of inadvertent injuries to the portal structures and presenting several issues. First, a Foley catheter often causes more friction than a red rubber intermittent urinary catheter. Second, placement through one of the two side holes of a Foley catheter may be more difficult with the location of the balloon, additional side holes, or gel lubricant, depending on the type of catheter. Third, the requirement of a surgical clip comes with a higher risk of damage to the portal structures and increased time of application or removal. Fernandez et al. described a similar hooking technique with a Foley catheter for use during LLR to include a hands off approach, which this protocol expands upon for a completely intracorporeal robotic application dictated by the primary surgeon from the robotic console without the need for a laparoscopic assist or use of clips^{10,12,14,15,17}.

The goal of this paper is to present a video of a robotic-adapted technique utilizing a readily available surgical tool (a 14-16 Fr red rubber intermittent urinary catheter, which is the standard carried size) to control hepatic blood flow during minimally invasive liver resection. This technique, to our knowledge, has not been previously described for use in robotic surgery and may facilitate easier implementation of an intracorporeal Pringle maneuver without adding significant expense, changes to surgical technique, or the addition of more incisions or new devices.

Protocol

A request for determination was submitted to the Oregon Health & Science University’s institutional review board under eIRB 27976 and accepted. Informed consent was obtained for use of intraoperative video footage. A glimpse of the surgical steps can be seen in Video 1.

1. Preoperative preparation

1. After induction of anesthesia, secure the patient onto the robotic bed and place the patient in about 20° of reverse Trendelenberg with the left side slightly down.
2. Utilizing the surgeon’s preferred method, achieve pneumoperitoneum and insert the camera port as the second robotic arm just superior to the level of the umbilicus in the right midclavicular line. Insert R1 in the right anterior axillary line, R3 in the left midclavicular line, and R4 in the left anterior axillary line.

2. Creation of the lasso

1. Create the intracorporeal Pringle device. Obtain a sterile 14-16 Fr red rubber catheter device and cut the catheter 15-20 cm from the eyelet end. Cut the funnel end off, then cut the separated funnel piece in half widthwise to create a neck to the lasso. Place the neck over the 15-20 cm portion of the red rubber catheter. Loop the distal end of the catheter into the neck to create an enclosed lasso (see Figure 1).
2. Prepare for insertion into the abdomen. Tighten the neck to decrease and increase the size of the lasso to ensure proper fit and ease of movement. Prior to inserting the catheter into the patient, unloop the catheter and place the neck slightly onto the straight portion of the catheter, prepped for insertion.

3. Surgical approach

1. Insert the unlooped catheter into the patient through the assistant port or one of the 12 mm robotic ports.
2. Dissect out the hepatoduodenal ligament. Remove any adhesions blocking the surgical field and dissect through the pars flaccida to expose the hepatoduodenal ligament. Skeletonize the hepatoduodenal ligament as much as needed in order to sufficiently access the Foramen of Winslow.
3. Place the lasso for the Pringle. Thread the straight portion of the catheter through the foramen of Winslow and around the hepatoduodenal ligament. Grab the neck of the lasso with the R3 instrument through it so the forceps are able to grab other materials. Hand the medial and then the lateral aspects of the straight portion of the catheter to the instrument in R3 so that the catheter is looped through the neck of the lasso. Tighten and loosen the neck on the lasso as needed to ensure appropriate cessation and restoration of hepatic inflow (see Figure 2).

4. Post-operative steps and care

1. Remove the red rubber catheter back through one of the robotic ports or laparoscopic assist port whenever the surgeon no longer needs intracorporeal vascular control.
2. Undock the robot and close the incisions from the robotic port sites with buried subcutaneous absorbable sutures.
3. Check post-operative hemoglobin/hematocrit based on clinical suspicion.

Results

This methodology of implementing the Pringle maneuver utilizing a readily available red rubber catheter ensures constant control by the primary operating surgeon and minimizes the chance for error between the coordination of bedside assist and the lack of proper tightening technique. A total of 8 patients (mean age of 47.8 ± 15.5 years, mean BMI 33.2 ± 6.1), underwent robotic liver resection over the past 3 years by a single surgeon at this institution using this red rubber catheter lasso technique, compared to 12 patien...

Discussion

Hepatic vascular control is of paramount importance in all hepatic resection approaches; however, RLR presents a specific challenge of autonomy of control by the senior surgeon, differing from previous laparoscopic requirements. Intermittent Pringle maneuver has been shown to be an effective and safe mechanism for controlling bleeding during hepatic resection, but translating this into an intracorporeal technique for use at the robotic console has yet to be standardized¹⁸.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
14-16 Fr all purpose urethral catheter	Bard	277716	Soft, red rubber urethral catheter
Cadiere Forceps	R2 Surgical	420049, 470049	Main robotic instrument used for the left hand, positioning of catheter around the hepatoduodenal ligament
Maryland Bipolar Forceps	R2 Surgical	420172, 470172	Right handed robotic instrument used to position the funneled end as the lasso tightener
Permanent Electrocautery Hook	R2 Surgical	420183, 470183	Cautery hook used for adhesion clearing