Safe Encirclement of the Hepatoduodenal Ligament Using ICG-Fluorescent Gauze for a Challenging Pringle Maneuver in Minimally Invasive Hepatectomy.

The Pringle maneuver (PM) is a widely accepted technique for inflow control during minimally invasive liver resection (MILR). However, postoperative adhesions following abdominal surgery make safe encirclement of the hepatoduodenal ligament technically challenging. Indocyanine green (ICG)-dyed gauze has recently been reported as a useful adjunct in minimally invasive surgery, with potential utility as an anatomical marker to guide surgeons and thereby enhance surgical safety, including by helping prevent gauze remnants. We describe a simple stepwise technique using ICG-fluorescent gauze as a landmark during a challenging PM. The ICG-dyed gauze was gently placed on the dorsal side of the hepatoduodenal ligament (HDL), and its fluorescence provided a clear landmark during adhesion division between the remnant stomach and the HDL. After widening the gate to divide the adhesions by following the fluorescence from the ICG-dyed gauze, the HDL was encircled with tape, and PM was safely performed without organ injury or other complications. This practical method may enhance safety during technically challenging PM in MILR.