Skip to main content
Download PDF

Inflow control can be safely used in laparoscopic subsegmentectomy of the liver: a single-center 10-year experience

BMC Surgery volume 23, Article number: 366 (2023) Cite this article

Abstract

Background

Several techniques have been developed to reduce blood loss in liver resection. The half-Pringle and Pringle maneuvers are commonly used for inflow control. This study compared the outcomes of different inflow control techniques in laparoscopic subsegmentectomy.

Methods

From October 2010 to December 2020, a total of 362 laparoscopic liver resections were performed by a single surgeon (C.C. Yong) in our institute. We retrospectively enrolled 133 patients who underwent laparoscopic subsegmentectomy during the same period. Perioperative and long-term outcomes were analyzed.

Results

The 133 patients were divided into 3 groups: no inflow control (n = 49), half-Pringle maneuver (n = 46), and Pringle maneuver (n = 38). A lower proportion of patients with cirrhosis were included in the half-Pringle maneuver group (P = .02). Fewer patients in the half-Pringle maneuver group had undergone previous abdominal (P = .01) or liver (P = .02) surgery. The no inflow control group had more patients with tumors located in the anterolateral segments (P = .001). The no inflow control group had a shorter operation time (P < .001) and less blood loss (P = .03). The need for blood transfusion, morbidity, and hospital days did not differ among the 3 groups. The overall survival did not significantly differ among the 3 groups (P = .89).

Conclusions

The half-Pringle and Pringle maneuvers did not affect perioperative or long-term outcomes during laparoscopic subsegmentectomy. The inflow control maneuvers could be safely performed in laparoscopic subsegmentectomy.

Peer Review reports

Introduction

Massive blood loss and blood transfusion during surgery adversely affect the outcomes of liver resection [1,2,3,4,5]. Thus, vascular inflow control is crucial in liver resection. Several techniques have been developed to reduce blood loss during liver resection, especially during laparoscopic surgery [6,7,8]. The technique of transient hepatic inflow occlusion for inflow control, also known as the Pringle maneuver, was first described by Pringle in patients with liver trauma and has been widely used in liver resection to reduce blood loss during liver resection surgery [9]. Moreover, this technique could be successfully performed during laparoscopic surgery [10]. However, the Pringle maneuver can lead to ischemic reperfusion injury [11, 12]. The effect of prolonged ischemic injury was more severe in patients with chronic liver diseases or cirrhosis [13,14,15,16]. Subsequently, hemihepatic vascular control, also known as the half-Pringle maneuver, was developed [17].

Compared with the Pringle maneuver, the half-Pringle maneuver can efficiently reduce blood loss and results in a lower risk of ischemic perfusion injury [18,19,20,21]. In addition, the half-Pringle maneuver prevents splanchnic congestion and has more favorable hemodynamic tolerability [22, 23]. Additional improvements in the technique and the nonrequirement of hilum dissection have enhanced the feasibility and safety of the half-Pringle maneuver technique [24,25,26].

Optimal inflow control relies on the location and extent of resection. This study compared the outcomes of different inflow control techniques in laparoscopic subsegmental hepatectomy.

Materials and methods

This study was approved by the Chang Gung Medical Foundation Institutional Review Board (approval number: 202101465B0). We retrospectively reviewed the data of patients who underwent laparoscopic subsegmentectomy between October 2010 and December 2020 at Kaohsiung Chang Guang Memorial Hospital. We collected patient information on clinical characteristics and perioperative and long-term follow-up outcomes. During the study period, we performed laparoscopic hepatectomy in 362 patients, of whom 133 underwent laparoscopic subsegmentectomy for liver tumors, either malignant or benign lesions, that was conducted by a single surgeon (C.C. Yong). We retrospectively analyzed the 133 patients and divided them into 3 groups on the basis of the technique used for inflow control: no inflow control, half-Pringle maneuver, and Pringle maneuver. The surgeon decided which technique was used based on his own judgment and experience. Mostly, we would not use inflow control at first. In cirrhosis or difficult-to-approach cases (easy bleeding or difficult tumor locations), we would shift to the half-Pringle method as long as the liver hilum could be approached. If the case had adhesion over the liver hilum, we introduced the Pringle maneuver. (Fig. 1).

Fig. 1
figure 1

Algorithm of selection of inflow control methods in laparoscopic subsegmentectomy. * Difficult conditions meant easy bleeding or difficult tumor locations

Full size image

The liver anatomy and resection were defined according to the Brisbane 2000 terminology [27]. In all the patients included in this study, less than a segment of the liver was laparoscopically resected. The difficulty of liver resections was determined using the Iwate score [28] and Institut Mutualiste Montsouris (IMM) scoring system [29]. Surgical morbidities were examined using the Clavien–Dindo classification [30]. Cirrhosis was confirmed by pathologists with the specimen being resected.

Surgical technique

The surgical technique was similar to that reported in previous studies [17, 31]. Briefly, the patient was placed in the supine position, and a 10-mm trocar was inserted in the umbilical wound for inflation. The pressure was maintained at 12 mmHg in the pneumoperitoneum. Other trocars were placed according to the procedure. Without hilar dissection, we placed a vascular clamp (Aesculap, Center Valley, PA, USA) at the right or left pedicle depending on the location of the lesion by adopting the extra-Glissonian approach to induce hemivascular occlusion. Subsequently, the half-Pringle maneuver was performed once the ischemic demarcation line was observed and the lesion was localized through intraoperative ultrasound. Initially, when the Pringle maneuver was needed, we used a large vascular clamp to occlude inflow. We have been using Huang’s loop since its development in 2018 [10]. Both the half-Pringle and Pringle maneuvers were intermittently performed with a 15-minute clamp and a 5-minute declamp.

Liver parenchymal transection was performed using the harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH, USA) or the Thunderbeat (Olympus, Center Valley, PA, USA) with the Kelly clamp crushing technique. The vessels on the transection line were controlled using metal clips, vascular locks, or sutures.

Peri-operative anesthesia setting

We routinely kept the CVP level below 5 mmHg before and during transecting the parenchyma. The ventilator setting depended on clinical condition. When bleeding was still noted after inflow was controlled, the bleeding was mainly from the venous back flow. Then the anesthesiologist would reduce the tidal volume down to 6 ~ 8ml/kg of ideal body weight to reduce blood loss.

Postoperative care

All patients were transferred to the intensive care unit for further care postoperation. All care principles were the same in our center. Postoperative biochemical data, including serum total bilirubin, alanine aminotransferase, aspartate aminotransferase, albumin, creatinine, and C-reactive protein levels; prothrombin time; and international normalized ratio, were examined on postoperative days 1, 2, 3, 5, and 7. Posthepatectomy liver failure was defined and graded according to the International Study Group for Liver Surgery (ISGLS) guidelines [32]. Perioperative mortality was defined as death within 90 days of surgery and death during the same hospital admission for surgery.

Statistical analysis

Categorical variables were compared using the Pearson chi-square test. All continuous variables are expressed as the means and were analyzed through one-way analysis of variance with post hoc Tukey’s test. The Kaplan–Meier curve was plotted for survival analysis, and data were compared among the 3 groups by using the log-rank test. A 2-sided P value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics for Windows 20.0 (IBM Corp., Armonk, NY, USA).

Results

From October 2010 to December 2020, a total of 133 patients who underwent laparoscopic subsegmentectomy were recruited for this study. All patients were divided into 3 groups on the basis of the technique used for inflow control during liver resection: no inflow control (n = 49), half-Pringle maneuver (n = 46), and Pringle maneuver (n = 38). Table 1 lists the demographics of the patients. The proportion of patients with cirrhosis was lower in the half-Pringle maneuver group than in the other groups (no inflow control vs. half-Pringle, P = .06; half-Pringle vs. Pringle, P = .006) (Table 1; Fig. 2). Furthermore, fewer patients in the half-Pringle maneuver group had previously undergone abdominal surgery (P = .01) and liver surgery (P = .02). A higher proportion of the patients in the no inflow control group exhibited tumors located at the anterolateral segments (Table 2, P = .001). Furthermore, the Iwate scores were lower in the no inflow control group (Table 2, P = .002). The IMM scores were lower in the no inflow control group (Table 2, P = .02).

Table 1 Clinical characteristics of patients (n = 133)
Full size table
Fig. 2
figure 2

The proportion of patients with cirrhosis was lower in the half-Pringle group than in the other groups

Full size image
Table 2 Tumor locations and difficulty scores
Full size table

The no inflow control group had a shorter operation time (Table 3, P < .001) and less blood loss (Table 3, P = .03). No differences in the need for blood transfusion, morbidity, or hospital days were noted among the 3 groups. The pathology results details were shown in Table 4.

Table 3 Perioperative outcomes, n = 133
Full size table
Table 4 Pathology results
Full size table

Four patients developed complications with a Clavien–Dindo classification higher than grade 3 (Table 5). A 71-year-old man in the half-Pringle maneuver group developed bile leakage postoperation. He underwent endoscopic retrograde biliary drainage with a plastic stent. However, the patient developed postendoscopic retrograde cholangiopancreatography pancreatitis after the procedure. A 58-year-old man in the no inflow control group developed ISGLS grade A posthepatectomy liver failure and pneumonia. Another 66-year-old man in the no inflow control group received surgery for bowel obstruction due to adhesion on postoperative day 7 and developed sepsis. A 64-year-old man in the Pringle maneuver group developed an intraabdominal abscess and was readmitted for CT-guided drainage on postoperative day 16. All patients recovered well after treatment and were discharged. No 30-day or 90-day mortality was noted in this study.

Table 5 Complications
Full size table

No significant difference in overall survival was noted among the 3 groups (P = .89; Fig. 3).

Fig. 3
figure 3

Overall survival. No significant difference in overall survival was noted among the three groups. Log Rank test: P = .89

Full size image

Discussion

Several inflow control techniques have been developed to reduce blood loss during liver resection, and the procedures have been reported to be feasible and safe [24,25,26]. We used both the Pringle maneuver and half-Pringle maneuver with the extra-Glissonian approach in laparoscopic subsegmentectomy. The results of our study revealed that the half-Pringle maneuver was performed in fewer patients who underwent previous abdominal or liver surgery because the adhesion of the hilum in previous surgery caused difficulty in performing the half-Pringle maneuver. In this situation, we performed the Pringle maneuver at a lower level of the portal triad to prevent hilum injury if inflow control was needed.

The choice of the optimal inflow control method relies on the complexity of procedures and the location of tumors. More definite inflow control might be required in more complicated conditions, such as in patients with portal hypertension. The half-Pringle maneuver might be appropriate in a small liver lesion in a few segments requiring minor resection [17, 31]. Our results indicated that a higher proportion of the patients with tumors located in the anterolateral segments (S2-S6) did not require any inflow control. Furthermore, more patients who received either the half-Pringle or Pringle maneuver had higher Iwate scores. This finding is consistent with our clinical judgment that the anterolateral location is easier to approach and reduces the need for inflow control. Higher Iwate scores indicated more difficulty in surgical techniques, thus possibly requiring inflow control. Although the Iwate score did not significantly differ among the groups, the IMM scores were lower in the no inflow control group. We believed that this result was not meaningful because our study focused only on subsegmentectomy; thus, selection bias might have been caused by other factors, such as tumor size and extent of liver resection, which did not differ among the groups. We recommend not using the Iwate or IMM score in laparoscopic subsegmentectomy as guidance for deciding the inflow control method.

In terms of perioperative data, the mean operation time was shorter in the no inflow control group, possibly because we did not perform inflow control in simple cases with less difficult location detection and less bleeding tendency and routinely used intermittent inflow control with either the half-Pringle or Pringle method rather than continuous occlusion. The declamp time might have caused an increase in operation time. Although the continuous half-Pringle method has been proven to be safe and beneficial compared with the intermittent Pringle maneuver even in patients with cirrhosis, [18, 19, 33, 34] we still used intermittent methods to reduce the risk of prolonged ischemia. For laparoscopic subsegmentectomy, the total operation time in our study group was approximately 200 minutes. The declamp time caused a slight increase in operation time. Thus, we believe that the benefits of intermittent inflow control would overcome the shortage of a prolonged operation time in limited liver resection.

The results of our study indicated that blood loss was lower in the no inflow control group. This might be a selection bias in this result. We attempted liver resection without any inflow control in easy-to-approach cases. However, we introduced inflow control once bleeding occurred during surgery and could not be controlled easily. Then, these cases were shifted to the inflow control groups. Thus, blood loss was greater in the half-Pringle and Pringle maneuver groups. Nevertheless, the postoperative data, including hospital days, major complications, and long-term survival, were not different among the 3 groups. Only one patient developed grade A posthepatectomy liver failure in the no inflow group. No patient developed liver failure in the half-Pringle or Pringle maneuver group.

The perioperative data and long-term outcomes were similar in the half-Pringle and Pringle maneuver groups; this finding is consistent with those of previous studies [35, 36]. Previous studies have reported fluctuations in liver enzymes post hepatectomy and less liver injury and earlier liver function recovery in patients who received the half-Pringle technique [18, 33, 37]. Our data revealed similar results for liver enzyme fluctuations, which are not shown in the tables. All the patients in the half-Pringle and Pringle maneuver groups recovered to baseline conditions without impaired perioperative and long-term outcomes; however, this finding was not clinically significant. The risk of posthepatectomy liver failure still cannot be neglected, especially in patients with chronic liver disease or cirrhosis. The choice of inflow control was dependent on the case. Similar to Horgan et al., [17] we suggest that the half-Pringle technique appears to be more suitable for patients with lesions in the hemiliver undergoing limited resection. The selective use of the half-Pringle technique can prevent unnecessary parenchymal ischemia. If the half-Pringle maneuver fails to occlude inflow, the Pringle maneuver might be an alternative effective technique. Although the Pringle maneuver might increase the risk of ischemic injury, no inferior short-term outcome of hepatectomy was seen in our study, even in the group with more cirrhotic liver and higher difficult scores. Therefore, although we need to adopt the Pringle maneuver in more challenging cases, laparoscopic hepatectomy can still be performed without compromising outcomes.

The half-Pringle technique resulted in adequate inflow control and was easy to perform. This technique avoids complex dissection to control selective inflow vessels. Previous studies [17, 31, 33] and the present study have demonstrated that this technique is feasible and safe for laparoscopic subsegmentectomy. Therefore, we suggest that the half-Pringle maneuver should be used when inflow control is needed. The half-Pringle maneuver not only reduces blood loss without requiring dissection of the hilum but also prevents unnecessary ischemic injury, which is a major concern in the Pringle maneuver.

This study has some limitations that should be addressed. First, this is a retrospective single-surgeon and single-center study; thus, selection bias was the biggest shortcoming. Second, our study was not randomized. The decision regarding the choice of the inflow control method was made by the surgeon. Finally, our data included different etiology cases, which might cause bias in long-term survival. A multicenter and multiple-surgeon study with a larger sample size should be conducted to confirm our results. Despite the limitations, we showed the solid data that inflow control did not compromise the perioperative and long-term outcomes in laparoscopic subsegmentectomy.

Conclusions

The half-Pringle and Pringle maneuvers could be safely used when performed during laparoscopic subsegmentectomy without compromising perioperative or long-term outcomes. The half-Pringle technique is easy to perform and can be the first choice and alternative to the Pringle maneuver.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

IMM:

Institut Mutualiste Montsouris

ISGLS:

International Study Group for Liver Surgery

References

  1. Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg Oct. 2002;236(4):397–406. discussion 406 – 397.

    Article  Google Scholar 

  2. Nagino M, Kamiya J, Arai T, Nishio H, Ebata T, Nimura Y. One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome. Surg Feb. 2005;137(2):148–55.

    Google Scholar 

  3. Katz SC, Shia J, Liau KH, et al. Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma. Ann Surg Apr. 2009;249(4):617–23.

    Article  Google Scholar 

  4. Nagao T, Inoue S, Goto S, et al. Hepatic resection for hepatocellular carcinoma. Clinical features and long-term prognosis. Ann Surg Jan. 1987;205(1):33–40.

    Article  CAS  Google Scholar 

  5. Shimada M, Matsumata T, Akazawa K, et al. Estimation of risk of major Complications after hepatic resection. Am J Surg Apr. 1994;167(4):399–403.

    Article  CAS  Google Scholar 

  6. Dua MM, Worhunsky DJ, Hwa K, Poultsides GA, Norton JA, Visser BC. Extracorporeal Pringle for laparoscopic liver resection. Surg Endosc Jun. 2015;29(6):1348–55.

    Article  Google Scholar 

  7. Nomi T, Fuks D, Agrawal A, Govindasamy M, Araki K, Gayet B. Modified Pringle maneuver for laparoscopic liver resection. Ann Surg Oncol Mar. 2015;22(3):852.

    Article  Google Scholar 

  8. Jiao H, Tan J, Chu Y, Zhu Z, Dong JH. Modified hepatic vascular occlusion facilitates hepatectomy for malignant hepatic Tumor in laparoscopy. Surg Laparosc Endosc Percutan Tech Dec. 2014;24(6):506–11.

    Article  Google Scholar 

  9. Pringle JHV. Notes on the arrest of hepatic Hemorrhage due to Trauma. Ann Surg Oct. 1908;48(4):541–9.

    Article  CAS  Google Scholar 

  10. Huang JW, Su WL, Wang SN. Alternative laparoscopic Intracorporeal Pringle Maneuver by Huang’s Loop. World J Surg Oct. 2018;42(10):3312–5.

    Article  Google Scholar 

  11. Cherqui D, Goëré D, Brunetti F, Malassagne B, Fagniez PL. [Selective use of vascular clamps in major hepatectomy]. Chirurgie Dec. 1999;124(6):632–9.

    Article  CAS  Google Scholar 

  12. Montalvo-Jave EE, Escalante-Tattersfield T, Ortega-Salgado JA, Piña E, Geller DA. Factors in the pathophysiology of the liver ischemia–reperfusion injury. J Surg Res Jun. 2008;1(1):153–9.

    Article  Google Scholar 

  13. Man K, Fan ST, Ng IO, et al. Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors. Arch Surg May. 1999;134(5):533–9.

    Article  CAS  Google Scholar 

  14. Wu CC, Hwang CR, Liu TJ, P’Eng FK. Effects and limitations of prolonged intermittent ischemia for hepatic resection of the cirrhotic liver. Br J Surg Jan. 1996;83(1):121–4.

    Article  CAS  Google Scholar 

  15. Ezaki T, Seo Y, Tomoda H, Furusawa M, Kanematsu T, Sugimachi K. Partial hepatic resection under intermittent hepatic inflow occlusion in patients with chronic Liver Disease. Br J Surg Mar. 1992;79(3):224–6.

    Article  CAS  Google Scholar 

  16. Nishimura T, Nakahara M, Kobayashi S, Hotta I, Yamawaki S, Marui Y. Ischemic injury in cirrhotic livers: an experimental study of the temporary arrest of hepatic circulation. J Surg Res Sep. 1992;53(3):227–33.

    Article  CAS  Google Scholar 

  17. Horgan PG, Leen E. A simple technique for vascular control during hepatectomy: the half-pringle. Am J Surg Sep. 2001;182(3):265–7.

    Article  CAS  Google Scholar 

  18. Fu SY, Lau WY, Li GG, et al. A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy. Am J Surg Jan. 2011;201(1):62–9.

    Article  Google Scholar 

  19. Ni JS, Lau WY, Yang Y, et al. A prospective randomized controlled trial to compare pringle maneuvermanoeuvre with hemi-hepatic vascular inflow occlusion in liver resection for hepatocellular carcinoma with Cirrhosis. J Gastrointest Surg Aug. 2013;17(8):1414–21.

    Article  Google Scholar 

  20. Chau GY, Lui WY, King KL, Wu CW. Evaluation of effect of hemihepatic vascular occlusion and the Pringle maneuver during hepatic resection for patients with hepatocellular carcinoma and impaired liver function. World J Surg Nov. 2005;29(11):1374–83.

    Article  Google Scholar 

  21. Machado MA, Makdissi FF, Bacchella T, Machado MC. Hemihepatic ischemia for laparoscopic liver resection. Surg Laparosc Endosc Percutan Tech Jun. 2005;15(3):180–3.

    Article  Google Scholar 

  22. Zhang Y, Yang H, Deng X, Chen Y, Zhu S, Kai C. Intermittent Pringle maneuver versus continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection. Surg Endosc Mar. 2016;30(3):961–70.

    Article  Google Scholar 

  23. Belghiti J, Marty J, Farges O. Techniques, hemodynamic monitoring, and indications for vascular clamping during liver resections. J Hepatobiliary Pancreat Surg. 1998;5(1):69–76.

    Article  CAS  PubMed  Google Scholar 

  24. Chen H, Wang F, Deng F, Zhen Z, Lai EC, Lau WY. Laparoscopic right hemihepatic vascular inflow occlusion by lowering of the hilar plate. J Laparoendosc Adv Surg Tech A Dec. 2014;24(12):833–6.

    Article  Google Scholar 

  25. Herman P, Kruger J, Lupinacci R, Coelho F, Perini M. Laparoscopic bisegmentectomy 6 and 7 using a glissonian approach and a half-pringle maneuver. Surg Endosc May. 2013;27(5):1840–1.

    Article  Google Scholar 

  26. Rotellar F, Pardo F, Benito A, Martí-Cruchaga P, Zozaya G, Pedano N. A novel extra-glissonian approach for totally laparoscopic left hepatectomy. Surg Endosc Sep. 2012;26(9):2617–22.

    Article  Google Scholar 

  27. Strasberg SM, Belghiti J, Clavien PA, et al. The Brisbane 2000 terminology of liver anatomy and resections. Hpb. 2000;2(3):333–9.

    Article  Google Scholar 

  28. Wakabayashi G. What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection? Hepatobiliary Surg Nutr Aug 2016;5(4):281–289.

  29. Kawaguchi Y, Fuks D, Kokudo N, Gayet B. Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg Jan. 2018;267(1):13–7.

    Article  Google Scholar 

  30. Dindo D, Demartines N, Clavien PA. Classification of Surgical Complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg Aug. 2004;240(2):205–13.

    Article  Google Scholar 

  31. Herman P, Perini MV, Coelho F, Saad W, D’Albuquerque LA. Half-pringle maneuver: a useful tool in laparoscopic liver resection. J Laparoendosc Adv Surg Tech A Feb. 2010;20(1):35–7.

    Article  Google Scholar 

  32. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy Liver Failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surg May. 2011;149(5):713–24.

    Article  Google Scholar 

  33. Zhang Y, Lu X, Xu J, et al. Intermittent Pringle Versus continuous half-pringle maneuver for laparoscopic liver resections of tumors in segment 7. Indian J Surg Apr. 2018;80(2):146–53.

    Article  Google Scholar 

  34. Liang G, Wen T, Yan L, et al. A prospective randomized comparison of continuous hemihepatic with intermittent total hepatic inflow occlusion in hepatectomy for liver tumors. Hepatogastroenterology May-Jun. 2009;56(91–92):745–50.

    Google Scholar 

  35. Tanaka K, Shimada H, Togo S, Nagano Y, Endo I, Sekido H. Outcome using hemihepatic vascular occlusion versus the pringle maneuver in resections limited to one hepatic section or less. J Gastrointest Surg Jul-Aug. 2006;10(7):980–6.

    Article  Google Scholar 

  36. Figueras J, Llado L, Ruiz D, et al. Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial. Ann Surg Apr. 2005;241(4):582–90.

    Article  Google Scholar 

  37. Wang HQ, Yang JY, Yan LN. Hemihepatic versus total hepatic inflow occlusion during hepatectomy: a systematic review and meta-analysis. World J Gastroenterol Jul. 2011;14(26):3158–64.

    Google Scholar 

Download references

Acknowledgements

This manuscript was edited by Wallace Academic Editing.

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Surgery, Division of General Surgery, Chang Gung Memorial Hospital, Kaohsiung, No. 123, Dapi Rd., Niaosong Dist, Kaohsiung City, 833401, Taiwan

    Hao-Ping Wang, Teng-Yuan Hou, Wei-Feng Li & Chee-Chien Yong

Authors
  1. Hao-Ping Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Teng-Yuan Hou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wei-Feng Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chee-Chien Yong
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Hao-Ping Wang contributed to the acquisition, analysis, or interpretation of data for the work, drafting the work, final approval of the version to be published and agreement to be accountable for all aspects of the work. Teng-Yuan Hou contributed to the acquisition, analysis, or interpretation of data for the work, revision of the work, final approval of the version to be published and agreement to be accountable for all aspects of the work. We-Feng Li contributed to the acquisition, analysis, or interpretation of data for the work, revising the work, final approval of the version to be published and agreement to be accountable for all aspects of the work. Chee-Chien Yong contributed to the conception or design of the work, acquisition, analysis, or interpretation of data for the work, revision of the work, final approval of the version to be published and agreement to be accountable for all aspects of the work.

Corresponding author

Correspondence to Chee-Chien Yong.

Ethics declarations

Ethics approval

This study was approved by the Chang Gung Medical Foundation Institutional Review Board (approval number: 202101465B0) of Chang Gung Memorial Hospital. Informed consent was waived by Chang Gung Medical Foundation Institutional Review Board due to retrospective research.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wang, HP., Hou, TY., Li, WF. et al. Inflow control can be safely used in laparoscopic subsegmentectomy of the liver: a single-center 10-year experience. BMC Surg 23, 366 (2023). https://0-doi-org.brum.beds.ac.uk/10.1186/s12893-023-02282-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s12893-023-02282-2

Keywords

BMC Surgery

ISSN: 1471-2482

Contact us