The Pringle manoeuvre describes a technique frequently used in liver surgery to control bleeding while dividing the liver parenchyma (liver substance) by applying a clamp or other compressive device to the porta hepatis at the foramen of Winslow as shown in the figure below. This effectively stops blood flow into the liver by occluding the portal vein and hepatic artery or arteries. But who was Pringle and how was this technique first described?
James Hogarth Pringle was born in Australia in 1863 in Parramatta which is now a suburb of Sydney. He enrolled to study medicine in the University of Edinburgh and graduated in 1885. After qualifying as a doctor he trained as a surgeon in a variety of posts around Europe. He returned to Scotland and worked with Sir Wiliam McEwen and was employed as a surgeon at Glasgow Royal Infirmary between 1896 and 1923. At this period in history it was common for surgeons to operate on all kinds of patients and to perform both orthopaedic and general surgery procedures. It was a long time later that subspecialization came about.
During this time Pringle decided to write up a series of 8 patients who had severe liver trauma who were under his care. The article was published in the eminent journal Annals of Surgery. This is the most extraordinary account that I think I have ever read. Of the 8 patients 3 had such serious liver injuries or associated head or other injuries that they did not reach the operating theatre and one patient who may have had a survivable injury steadfastly refused to submit himself to surgery and died of his injuries on the third day after presentation. The remaining 4 patients all went to surgery and it was on these patients that I assume Pringle based his observations. What he proposed was that when blood was issuing from the fractured liver, it might be possible to temporarily control the bleeding by occluding the portal vein in the free edge of the foramen of Winslow. This would then allow a clear field and allow an attempt to repair or control the site of haemorrhage in the liver itself.
Pringle’s theory was clearly better than his practice as two of the four remaining patients died on the operating table however two patients did survive to the recovery room only to die some time after. I do not mean to be even remotely critical of Pringle as a surgeon and there are many reasons why his patients may have died unrelated to his actual surgery. The approach has withstood the test of time, is a key means of controlling bleeding from liver injuries in both the emergency and the elective setting and has undoubtedly saved many thousands of lives.
If you want to read Pringle’s original paper ( and I would urge you to do so) you can get it here. It must be one of the only papers published in Annals of Surgery with a 100% mortality and only the most rudimentary data. There are however, some interesting additional insights, for example Pringle describes abdominal tamponade of bleeding and that some minor liver injuries are likely to be survivable without surgery at all. The editors must have been able to see through to the genuine potential of this universally accepted technique!
Pringle lived to be 78 and died in 1941.