EXTERNAL PRINGLE MANEUVER IN LAPAROSCOPIC LIVER RESECTION: A SAFE, CHEAP AND REPRODUCIBLE WAY TO PERFORM IT

ABSTRACT Background: Laparoscopic liver resection is performed worldwide. Hemorrhage is a major complication and bleeding control during hepatotomy is an important concern. Pringle maneuver remains the standard inflow occlusion technique. Aim: Describe an extracorporeal, efficient, fast, cheap and reproducible way to execute the Pringle maneuver in laparoscopic surgery, using a chest tube. Methods: From January 2014 to March 2020, our team performed 398 hepatectomies, 63 by laparoscopy. We systematically encircle the hepatoduodenal ligament and prepare a tourniquet to perform Pringle maneuver. In laparoscopy, we use a 24 Fr chest tube, which is inserted in the abdominal cavity through a small incision. We thread the cotton tape through the tube, pulling it out through the external end, outside the abdomen. To perform the tourniquet, we just need to push the tube as we hold the tape, clamping both with one forceps. Results: The 24 Fr chest tube is firm and works perfectly to occlude blood inflow as the cotton band is tightened. It has an internal diameter of 5,5 mm, sufficient for a laparoscopic grasper pass through it to catch the cotton band, and an external diameter of 8 mm, which allows to be inserted in the abdomen through a tiny incision. The cost of this tube and the cotton band is less than US$ 1. No complications related to the method were identified in our patients. Conclusions: The extracorporeal Pringle maneuver presented here is a safe, cheap and reproducible method, that can be used for bleeding control in laparoscopic liver surgery.摘要 背景：腹腔镜肝切除术在全球范围内广泛开展。出血是其主要并发症，肝实质切开过程中的止血控制是临床重点关注的问题。普林格止血法（Pringle maneuver）仍是目前标准的入肝血流阻断技术。 研究目的：介绍一种利用胸管实施腹腔镜手术中普林格止血法的体外式、高效、快速、低成本且可重复的操作方案。 方法：2014年1月至2020年3月期间，本团队共完成398例肝切除术，其中63例为腹腔镜肝切除术。我们常规环绕肝十二指肠韧带并制备止血带以实施普林格止血法。在腹腔镜手术中，我们使用24 Fr胸管，通过小切口将其置入腹腔。将棉带穿过该胸管，经胸管外端引出至腹腔外。制备止血带时，只需在固定棉带的同时推送胸管，并用一把镊子同时夹持二者即可完成操作。 结果：24 Fr胸管质地坚硬，收紧棉带时可完美阻断入肝血流。该胸管内径为5.5 mm，足以容纳腹腔镜抓钳穿过以牵拉棉带；外径为8 mm，可通过微小切口置入腹腔。该胸管与棉带的总成本不足1美元。本研究纳入的患者中未发现与该操作方法相关的并发症。 结论：本文所介绍的体外式普林格止血法是一种安全、低成本且可重复的操作方案，可用于腹腔镜肝脏手术中的出血控制。