Safety of single continuous Pringle maneuver during HHA enucleation: a retrospective cohort study

To evaluate the impact of different Pringle maneuver strategies (continuous vs. intermittent) and occlusion durations on postoperative liver function and surgical outcomes after hepatic hemangioma (HHA) enucleation. This retrospective cohort study included 101 patients who underwent laparoscopic or robot-assisted HHA enucleation after excluding the early learning curve period. Patients were divided into four groups according to Pringle maneuver duration and strategy: continuous occlusion (< 20 min, 20–40 min, 40–70 min) and intermittent occlusion (cumulative 40–70 min with 15-min clamping/5-min reperfusion cycles). Postoperative complications, liver function changes, hospital stay, and multivariable-adjusted outcomes were compared. Baseline characteristics were comparable among groups except for larger hemangioma diameter in Group C (P < 0.05). Group D had longer operative time and greater blood loss (P < 0.05), while allogeneic transfusion rates were similar across groups. After multivariable adjustment, continuous Pringle maneuver remained independently associated with shorter operative time and less blood loss compared with intermittent occlusion. On postoperative day 3, GGT levels were higher in Groups C and D compared with Groups A and B, but no significant difference was observed between Groups C and D (P > 0.05). After adjustment for tumor size, the difference in GGT was no longer statistically significant. Postoperative day 5 AST differed significantly among groups but was not considered clinically meaningful. Major complication rates were low (3.0%) and did not differ by occlusion strategy. No cases of postoperative liver failure or reoperation occurred. Postoperative hospital stay was comparable across groups. In patients with normal liver function undergoing minimally invasive HHA enucleation, a single continuous Pringle maneuver of approximately 60 min (based on a median occlusion time of 51 min in Group C) appears safe and may offer advantages in operative efficiency and blood loss compared with intermittent clamping. However, given the absence of a precise 60-min control group and the non-randomized nature of the study, these findings should be considered preliminary. Larger prospective studies are warranted to confirm the exact safety threshold.