USMLE® Step 2 Question of the Day: Hepatocellular carcinoma

The correct answer to today's USMLE® Step 2 CK Question is...

D. Clamping of the hepatoduodenal ligament 

Before we get to the Main Explanation, let's see why the answer wasn't A, B, C, or E. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

Today's incorrect answers are...

A. Blood transfusion 

Incorrect: Blood transfusions, while an essential part of intraoperative hemostasis, have not been shown to mitigate morbidity and mortality in liver resections, and are negatively associated with post-operative complications.  

B. Adequate postoperative oral hydration 

Incorrect: Postoperative oral hydration has minimal effect on fluid hemostasis post-surgically and has no role in intraoperative hemostasis.  

C. Preoperative intravenous fluids 

Incorrect: Careful preoperative IV fluid management is critical for surgical candidates and, in particular, patients with underlying cardiopulmonary conditions. However, hemostasis during liver surgery can be better achieved by directly arresting blood flow to the majority of the liver via surgical clamping. 

E. Clamping of the cystoduodenal ligament  

Incorrect: Commonly mistaken for the hepatoduodenal ligament, clamping of the cystoduodenal ligament would not provide hemostatic control during resection of the liver. Blood flow to the liver is from the hepatic artery and hepatic portal vein. 

Main Explanation

The liver is a richly vascularized organ, thus acute life-threatening hemorrhage is a feared complication of liver resection. Management of intraoperative hemorrhage and strictly maintaining hemostatic control remains one of the most challenging aspects of hepatic surgery. Currently, the best way to achieve this goal is to clamp the hepatoduodenal ligament.  

The hepatoduodenal ligament contains the hepatic artery, portal vein, and common bile duct. Manual compression of this structure is known as the Pringle maneuver. The Pringle maneuver should be used only immediately before hepatic manipulation or resection, as prolonged use of the Pringle maneuver can lead to reperfusion injury of the liver.  

Major takeaway

The Pringle maneuver involves manually compressing the hepatoduodenal ligament to minimize blood loss l during hepatic surgery. The hepatoduodenal ligament is composed of the hepatic artery, portal vein, and common bile duct.

References

Piardi, T., Lhuaire, M., Memeo, R., et al. (2016) Laparoscopic Pringle maneuver: How we do it?. Hepatobiliary Surgery and Nutrition. 5(4), 345-349. Doi:10.21037/hbsn.2015.11.01. 

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