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Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure – First technical report

1 Department of Surgical Oncology, Robotics and New Technologies, Policlinico Abano; Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
2 Department of Surgical Oncology, Robotics and New Technologies, Policlinico Abano, Padua, Italy

Date of Submission30-Oct-2020
Date of Decision05-Mar-2021
Date of Acceptance22-Apr-2021
Date of Web Publication03-Jun-2021

Correspondence Address:
Antonio Pesce,
Department of Surgical Oncology, Robotics and New Technologies, Policlinico Abano, 1, Piazza Cristoforo Colombo, 35031 Abano Terme, Padua
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_275_20


Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Keywords: Colorectal cancer, hepatic cancer, inferior vena cava, minimally invasive surgery, robotics

How to cite this URL:
Marchegiani F, Pesce A, Damoli I, Huscher C. Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure – First technical report. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from:

  Introduction Top

Intraoperative blood loss during hepatectomy is a factor that seriously affects peri-operative outcomes. Even after adoption of selective or total inflow clamping, the main issue remains the blood loss from hepatic veins. Infrahepatic inferior vena cava (IVC) clamping is an emerging technical trick which guarantees a lower central venous pressure during liver surgery.[1] First described by Otsubo et al.[2] in 2004, it is broadly adopted in open surgery. A recently published meta-analysis suggested its safety and efficacy in reducing blood loss compared with the Pringle manoeuvre alone.[3] The new paradigm of minimally invasive approach is day-by-day increasing the volume of hepatic robotic surgery.[4],[5],[6] However, minimally invasive liver surgery is burdened by bleeding which impairs a safety view of surgical field. This bleeding comes mainly from hepatic veins, even though the abdominal pressure is maintained around 12–15 mmHg.

Recently, Zhang et al.[7] described the IVC preparation and clamping for laparoscopic extracapsular enucleation of giant liver haemangiomas without injuries and with a significant reduction in intraoperative blood loss and transfusion rates. The aim of this article was to describe the first safe robotic preparation and infra-hepatic clamping of the IVC for a right hepatectomy.

  Procedure Top

This was a known case of a 70-year-old female patient with synchronous hepatic metastases of the right lobe from colon cancer, scheduled for robotic right hepatectomy. Pre-operative thoraco-abdominal computed tomography-scan revealed a single metastatic lesion of diameter 33 mm × 28 mm between S7 and S8, as shown in [Figure 1], and another small hepatic lesion was detected intra-operatively by ultrasound in the segment VI.
Figure 1: Computed tomography scan, coronal view, revealing a single hepatic metastatic lesion of diameter 33 mm × 28 mm between S7 and S8

Click here to view

The patient was placed in a modified lithotomy and reverse Trendelenburg position, with the first assistant standing between the patient's legs. An incision was made in the site of the previous Pfannenstiel incision with insertion of OctoPort device and insufflation with air seal system. Placement of four 8-mm robotic trocars in sub-umbilical line, 2 cm above the bisiliac line. Docking of the DaVinci Xi robotic system. Additional 2 trocars 12 mm in right to left hypochondrium, respectively, were placed.

The main procedure steps of robotic total liver inflow exclusion can be divided in preparation time, maneuver time, and releasing time. Preparations steps are the following:

  1. Ligaments dissection and Pringle preparation: in order to start the procedure, the hepatic pedicle is isolated and surrounded with a cotton tape which is exteriorised from a 5-mm assistant trocar and passed through a tubular drain;
  2. Caval clamping isolation and preparation: the IVC is gently prepared by the adoption of two robotic forceps. The right forceps is passed behind the vena cava to retrieve the cotton tape [Figure 2].
Figure 2: Infrahepatic vena cava preparation before clamping

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After total inflow preparation, ultrasound intra-operative staging and vascular mapping of the liver are mandatory. Lesions have to be carefully identified to verify that the resection was properly planned in the pre-operative study. The adoption of a robotic probe allows the first surgeon to visualise the lesions, to confirm the vascular anatomy and the anatomical relationships. The monopolar hook is a simple tool to mark the section line. After planning the demolitive phase starts. The maneuver is described in these steps:

  1. Pringle manoeuvre: the tubular drain is gently pulled towards the pedicle and fixed with a Kocher to tighten the tourniquet
  2. Infra-hepatic IVC clamping: the cotton tape passed all around the IVC is tighten with a knot and a clip is applied to avoid the loosening during the operation [Figure 3] [Figure 4] [Figure 5]; the caval clamping was intermittent every 20 min and the patient was able to tolerate the procedure with a systolic blood pressure >80 mmHg
  3. Central venous pressure was maintaining around 5 mmHg during liver parenchymal transection
  4. Parenchymal transection: it starts with the incision of the liver border with a monopolar hook. The progressive exposure of vascular and biliary structures allows their bipolar coagulation and section. The parenchymal fracture is achieved by Kellyclasia performed with a Maryland forceps [Figure 6]. The assistant can use an advanced bipolar instrument for sealing and sectioning of the major vessels. The final step is the stapling of suprahepatic vein (or veins). Right hepatic vein was transected with a linear vascular endo-stapler through assistant's port as well as an accessory inferior right hepatic vein which was identified intra-operatively

  5. The release time is divided into two steps:
  6. Progressive unclamping of IVC and hepatic hilum: Cotton loops are released first on the hepatic pedicle then on the IVC. The release has to be progressive and gentle to visualise any bleeding
  7. Haemostasis of the cut surface: Small bleedings are controlled with bipolar coagulation or separate stitches. The transection surface can easily be compressed by cross stitches.
Figure 3: Infra-hepatic inferior vena cava clamping: The loop is passed around the inferior vena cava

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Figure 4: The cotton tape passed around the vena cava is tighten with a knot

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Figure 5: A clip is applied to avoid the loosening during surgery

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Figure 6: Safe and bloodless hepatic parenchymal transection

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The total operative time was 265 min. The intra-operative blood loss was 300 ml. The intra- and post-operative renal function was not affected. Intraoperative urine volume, post-operative blood urea nitrogen and creatinine values were normal after operation. The liver function tests, such as transaminases and total bilirubin levels increased in the first 2 days after surgery but they returned to normality ranges shortly. However, the patient developed post-operative peritoneal effusion which was treated with diuretics and evacuative paracentesis. The patient was discharge home 3 weeks after surgery.

  Discussion Top

There is no common agreement about the adoption of routine Pringle manoeuvre in liver resection. Even if the majority of authors prepare the manoeuvre, not everyone performs it by default. However, the IVC clamping is a very discussed topic because of its deep impact on cardiovascular system function and metabolic issues. In most cases, clamping IVC technique is well tolerated.[7],[8]

Zhang et al.[7] demonstrated that all of the liver function tests, such as transaminases and total bilirubin levels, did not fluctuate substantially and returned to normal ranges within a short period of time after surgery comparing the caval clamping group with Pringle manoeuvre group. Moreover, the infrahepatic IVC clamping does not affect the renal function, as confirmed in previous studies.[1],[7],[8]

While performing minimally invasive surgery, some authors described combination of these two techniques to reach an optimal bleeding control.[7] However, no reports are available concerning liver total inflow occlusion in robotic surgery.

The dexterity offered by the robotic platform and the safety of IVC preparation under magnified view are the key elements for a successful procedure.

Bleeding reduction is the key for achieving satisfactory outcomes in minimally invasive liver surgery, which is associated with a significant decrease in the incidence of post-operative morbidity and liver failure,[9] especially in HCC patients.[10],[11] Moreover, the presence of a clear operative field enhances the recognition of hepatic structure and their safe sealing. It is our opinion that this technique could be technically feasible, reproducible and safe for robotic major liver resections where bleeding has to be avoided to reduce major morbidity.

The limit of this procedure is that when adopted by young surgeons who are facing the learning curve, the dissection time becomes longer and the risk of severe complications unbalances the advantage of vascular occlusion. A proper training on minor robotic resections has to be reached before attempting a major resection with total inflow occlusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fancellu A, Petrucciani N, Melis M, Porcu A, Feo CF, Zorcolo L, et al. Usefulness of infra-hepatic inferior vena cava clamping during liver resection: A meta-analysis of randomized controlled trials. J Gastrointest Surg 2018;22:941-51.  Back to cited text no. 1
Otsubo T, Takasaki K, Yamamoto M, Katsuragawa H, Katagiri S, Yoshitoshi K, et al. Bleeding during hepatectomy can be reduced by clamping the inferior vena cava below the liver. Surgery 2004;135:67-73.  Back to cited text no. 2
Zhou Y, Zhang Z, Wan T. Effect of infrahepatic inferior vena cava clamping on bleeding during hepatic resection: A meta-analysis. Asian J Surg 2018;41:523-9.  Back to cited text no. 3
van der Poel MJ, Fichtinger RS, Bemelmans M, Bosscha K, Braat AE, de Boer MT, et al. Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands. HPB (Oxford) 2019;21:1734-43.  Back to cited text no. 4
Ratti F, Fiorentini G, Cipriani F, Catena M, Paganelli M, Aldrighetti L. Laparoscopic vs open surgery for colorectal liver metastases. JAMA Surg 2018;153:1028-35.  Back to cited text no. 5
Khan S, Beard RE, Kingham PT, Fong Y, Boerner T, Martinie JB, et al. Long-term oncologic outcomes following robotic liver resections for primary hepatobiliary malignancies: A multicenter study. Ann Surg Oncol 2018;25:2652-60.  Back to cited text no. 6
Zhang W, Wang J, Li C, Zhang Z, Dirie NI, Dong H, et al. Infrahepatic inferior vena cava clamping with Pringle maneuvers for laparoscopic extracapsular enucleation of giant liver hemangiomas. Surg Endosc 2017;31:3628-36.  Back to cited text no. 7
Kato M, Kubota K, Kita J, Shimoda M, Rokkaku K, Sawada T. Effect of infra-hepatic inferior vena cava clamping on bleeding during hepatic dissection: A prospective, randomized, controlled study. World J Surg 2008;32:1082-7.  Back to cited text no. 8
Serenari M, Ratti F, Zanello M, Guglielmo N, Mocchegiani F, Di Benedetto F, et al. Minimally invasive stage 1 to protect against the risk of liver failure: Results from the hepatocellular carcinoma series of the associating liver partition and portal vein ligation for staged hepatectomy Italian registry. J Laparoendosc Adv Surg Tech A 2020;30:1082-9.  Back to cited text no. 9
Trovato MA, Pesce A, Sofia M, Montineri A, Basile A, Palermo F, et al. Is BCLC algorithm useful in clinical practice? Study on 164 HCC patients. Hepatogastroenterology 2013;60:1742-5.  Back to cited text no. 10
Levi Sandri GB, de Werra E, Mascianà G, Colasanti M, Santoro R, D'Andrea V, et al. Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art. Hepatobiliary Surg Nutr 2016;5:478-84.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04