During a difficult hepatectomy, torrential bleeding arises from the raw surface of the liver. The surgeon applies a soft non-crushing clamp across the hepatoduodenal ligament and the bleeding stops. This manoeuvre controls haemorrhage primarily by occluding:

• A The hepatic veins at their confluence with the inferior vena cava
• B The right and left bile ducts together with the portal vein
• C The retrohepatic inferior vena cava
• D The portal vein and hepatic artery inflow ✓

Explanation

This is the Pringle manoeuvre, which occludes arterial and portal venous inflow within the hepatoduodenal ligament, the source of most parenchymal bleeding during liver transection since hepatic venous backflow pressure is low. It can be applied intermittently for up to about 15 to 20 minutes at a stretch in the normal liver with acceptable ischaemic tolerance. Failure of the manoeuvre suggests bleeding from hepatic veins or retrohepatic vena cava, which requires different exposure and often total vascular exclusion.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.