Copyright
©The Author(s) 2026. Published by Baishideng Publishing Group Inc. All rights reserved.
Utility of liver surface-guided encirclement of hepatoduodenal ligament for the Pringle maneuver in minimally invasive repeat liver resection
Yoichi Kawano, Takahiro Murokawa, Yuto Aoki, Akira Hamaguchi, Takashi Ono, Takahiro Haruna, Daigo Yoshimori, Toshiyuki Irie, Junji Ueda, Tetsuya Shimizu, Akira Matsushita, Mampei Kawashima, Ryo Ga, Hiroyasu Furuki, Tomohiro Kanda, Yukio Oshiro, Keisuke Minamimura, Masato Yoshioka, Nobuhiko Taniai, Yoshiharu Nakamura, Hiroshi Yoshida
Yoichi Kawano, Takahiro Murokawa, Akira Hamaguchi, Takashi Ono, Takahiro Haruna, Daigo Yoshimori, Junji Ueda, Tetsuya Shimizu, Akira Matsushita, Hiroshi Yoshida, Department of Gastroenterological Surgery, Nippon Medical School, Tokyo 113-8603, Japan
Yuto Aoki, Toshiyuki Irie, Mampei Kawashima, Ryo Ga, Yukio Oshiro, Keisuke Minamimura, Yoshiharu Nakamura, Department of Gastroenterological Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba 270-1694, Japan
Hiroyasu Furuki, Tomohiro Kanda, Department of Gastroenterological Surgery, Nippon Medical School Tama Nagayama Hospital, Tokyo 206-8512, Japan
Masato Yoshioka, Nobuhiko Taniai, Department of Gastroenterological Surgery, Nippon Medical School Musashi Kosugi Hospital, Kanagawa 211-8533, Japan
Co-first authors: Yoichi Kawano and Takahiro Murokawa.
Author contributions: Kawano T and Murokawa T conceived and designed the study, performed the experiments, and made equivalent and indispensable contributions to this manuscript as co-first authors; Kawano T, Murokawa T, and Aoki Y contributed to drafting the manuscript; Kawano T, Murokawa T, and Kawano Y contributed to the analysis and interpretation of data; Kawano T, Murokawa T, Taniai N, Nakamura Y, and Yoshida H contributed to the critical revision of manuscript; Murokawa T, Ga R, Hamaguchi A, Aoki Y, Ono T, Haruna T, Yoshimori D, Irie T, Furuki H, Ueda J, Shimizu T, Kawashima M, Kanda T, Oshiro Y, Minamimura K, Yoshioka M, and Matsushita A contributed to the acquisition of data. All authors read and approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the Ethics Review Committee of Nippon Medical School, No. 30-03-1107.
Informed consent statement: Since this is a retrospective study, informed consent has been waived.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: There is no additional data available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Takahiro Murokawa, MD, PhD, Department of Gastroenterological Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo 113-8603, Japan.
takahiro-murokawa@nms.ac.jp
Received: August 29, 2025
Revised: October 23, 2025
Accepted: December 2, 2025
Published online: January 7, 2026
Processing time: 129 Days and 16.3 Hours
BACKGROUND
Repeated application of the Pringle maneuver is a key obstacle to safe minimally invasive repeat liver resection (MISRLR). However, limited technical guidance is available.
AIM
To study the utility of newly developed Pringle taping method guided by liver surface in MISRLR.
METHODS
We retrospectively reviewed 72 cases of MISRLR performed by a single surgeon at two centers from August 2015 to July 2024. Beginning in October 2019, a liver surface-guided encirclement of hepatoduodenal ligament (LSEH) was used for repeat Pringle taping. Perioperative outcomes including Pringle taping success, operative time, blood loss, conversion rate, morbidity, and mortality were assessed.
RESULTS
Laparoscopic and robotic approaches were used in 63 patients and 9 patients, respectively. The median operative time, blood loss, and hospital stay were 331.5 minutes, 70 mL, and 8 days, respectively. Open conversion occurred in two cases (2.8%) due to severe adhesions and right renal vein injury. Clavien-Dindo grade ≥ III complications occurred in 5.6% of cases with no mortality. Anti-adhesion barriers were used in 54 patients (75.0%). LSEH was attempted in 57 cases, improving Pringle taping success from 33.0% to 91.4% (P < 0.001). LSEH succeeded in all patients with prior open liver resection (n = 11). Among 6 patients in whom LSEH failed, 3 patients (50.0%) had undergone a third liver resection, and 1 patient had a history of distal gastrectomy with choledochoduodenostomy.
CONCLUSION
The newly developed LSEH technique for Pringle taping in MISRLR was feasible, enhancing safety and reproducibility even in patients with a history of open liver resection.
Core Tip: We demonstrated an effective, reproducible technique for repeat Pringle maneuver in challenging minimally invasive repeat liver resection (MISRLR). We retrospectively evaluated 72 patients who underwent MISRLR and examined the impact of a modified Pringle taping technique guided by the caudate lobe of the liver as an anatomical landmark. A marked improvement in success rate of Pringle taping from 33.0% to 91.4% occurred following this modification with low morbidity and no mortality. Thus, the proposed method may enhance both safety and reproducibility in MISRLR, particularly for patients with a history of open liver resection.
