Utility of liver surface-guided encirclement of hepatoduodenal ligament for the Pringle maneuver in minimally invasive repeat liver resection

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.