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 su....

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....

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