Luigi Cioffi - Academia.edu (original) (raw)
Papers by Luigi Cioffi
In the 1990s laparoscopic liver surgery was considered an innovative, promising but very demandin... more In the 1990s laparoscopic liver surgery was considered an innovative, promising but very demanding technique reserved for benign lesions or selected cases where the malignant tumour could be removed by minor and superficial resection. Subsequently the widespread introduction of laparoscopic hepatectomy in the surgical community, due to improvements in laparoscopic techniques, technological advances in laparoscopic devices and even to increasing patient’ awareness and demand for these procedures, showed it was a safe, successful and well-tolerated treatment for a range of benign and neoplastic hepatic diseases. In fact, after the first laparoscopic partial hepatectomy, reported in 1992, the minimally invasive approach has been used increasingly in the management of hepatic diseases showing that despite several technical challenges, can obtain reduced operative blood loss, fewer early postoperative complications and shorter hospital stay with oncologic clearance and a survival rate si...
Chirurgia italiana
In the belief that the advantages stemming from a minimally invasive approach are significant, pa... more In the belief that the advantages stemming from a minimally invasive approach are significant, particularly in cirrhosis patients, we decided to apply this technique in the treatment of a group of patients suffering from HCC associated with cirrhosis. Sixteen patients (10 men, 6 women; mean age 60.1 years) underwent laparoscopic surgery for HCC associated with well compensated HCV-related liver cirrhosis (Child-Pugh class A; mean tumour size 2.9 cm). Seven of these lesions were located in the left liver and 9 in the right lobe. Laparoscopy was performed with a CO2 pneumoperitoneum (12-14 mmHg). The Pringle manoeuvre was not used. There was one conversion to laparotomy due to inadequate exposure. We performed 13 non-anatomical resections, 1 VI segmentectomy and 1 anatomical left lobectomy. None of the patients required blood transfusions. One patient died of severe respiratory distress syndrome on postoperative day 3. Major morbidity included 2 moderate postoperative ascites successf...
Open, Laparoscopic and Robotic Hepatic Transection, 2012
The introduction of new technological devices for efficient and fast hemostatic control during pa... more The introduction of new technological devices for efficient and fast hemostatic control during parenchymal transection has greatly enhanced the diffusion and safety of the laparoscopic approach in the field of liver surgery. In this chapter we review the usefulness of the ultrasonically activated device (USAD) for dissection of liver parenchyma during laparoscopic liver resection. Among the wide panorama of available devices, the USAD technology in our experience of 69 laparoscopic liver resections was revealed to be a useful tool in both the dissection and parenchymal transection phases. For instance, the Pringle maneuver was rarely needed to achieve a safe coagulating effect, even when prepared in case of major bleedings. USAD was demonstrated to be extremely efficient in mobilizing the liver by rapid and blood-less dissection of all suspending ligaments. Though there is a lack of data based on well-conducted controlled studies and further studies on a greater number of patients are needed, according to our experience, utilization of USAD may help to minimize blood loss during liver resection regardless of the condition of the liver, even in case of cirrhosis.
Updates in Surgery, 2013
After an initial period of scepticism, especially concerning technical and oncological problems, ... more After an initial period of scepticism, especially concerning technical and oncological problems, laparoscopic liver surgery (LLS) has become a feasible and safe technique. Over the past decade, the minimally invasive approach has been used increasingly in to manage hepatic diseases, showing that this technique in liver surgery, despite the technical challenges, reduces operative blood loss and results in fewer early postoperative complications, less postoperative analgesic drug consumption, and shorter hospital stay, with an oncologic clearance and a survival rate similar to that of open surgery [1–5]. Therefore, the place of laparoscopy in liver surgery is increasing, and many types of liver resections, including major hepatectomies, are now performed by laparoscopy in specialized centers [6–9]. Nevertheless, no international consensus on laparoscopic surgical management of liver lesions has been published, and no worldwide criteria exist for the indications for minimally invasive liver resection. Thus, there are no evidence-based criteria assisting the surgeon with management strategies for the laparoscopic treatment of liver tumors. For example, how large should the lesion be? Where should the lesion be located? Should we modify the well-accepted surgical indication only because we can perform a liver resection using a minimally invasive approach? Should we perform laparoscopic liver resection (LLR) only for benign lesions, or can we resect even malignant lesions by laparoscopy?
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2006
Surgical Endoscopy, 2009
Recurrence of cancer and the need for several surgical treatments are the Achilles&am... more Recurrence of cancer and the need for several surgical treatments are the Achilles' heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries. This report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery. The rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients. Laparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.
Journal of Hepato-Biliary-Pancreatic Surgery, 2006
Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery pr... more Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster. From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6-7.1 cm); all the lesions were localized in the anatomical left lobe (segments II-III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices. The mean operative time was 142 min (range, 120-180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days. The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.
Journal of Gastrointestinal Surgery, 2008
Hepatogastroenterology, 2011
Although multiple groups have reported initial success with single port laparoscopy, no consensus... more Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.
Journal of Hepato-Biliary-Pancreatic Surgery, 2009
Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the pro... more Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the procedure is gaining popularity. Minor laparoscopic resections have been widely reported. In contrast, major laparoscopic hepatectomy has been performed in only a limited number of cases. Hand-assisted laparoscopic liver surgery has been advocated in order to improve liver exposure and vascular control and increase the safety of the procedure. Transparenchymal en-bloc transection of the right portal triad has been reported to be safe and useful in open surgery. We describe a personal technique for hand-assisted right hemihepatectomy. With ultrasound guidance, the right hepatic pedicle is isolated intrahepatically and transected en bloc with a single firing of an endostapler. Parenchymal transection is carried out with ultrasonically activated or vessel-sealing devices together with endostaplers. The procedure was successfully accomplished in three patients. The Pringle maneuver was never performed. No intraoperative or postoperative complications occurred. This study is the first to report a technique of right hemihepatectomy that combines hand-assisted laparoscopy and an ultrasound-guided intrahepatic approach. This technique may be a useful option to simplify the operation, reduce operative time, and increase the safety of the procedure.
In the 1990s laparoscopic liver surgery was considered an innovative, promising but very demandin... more In the 1990s laparoscopic liver surgery was considered an innovative, promising but very demanding technique reserved for benign lesions or selected cases where the malignant tumour could be removed by minor and superficial resection. Subsequently the widespread introduction of laparoscopic hepatectomy in the surgical community, due to improvements in laparoscopic techniques, technological advances in laparoscopic devices and even to increasing patient’ awareness and demand for these procedures, showed it was a safe, successful and well-tolerated treatment for a range of benign and neoplastic hepatic diseases. In fact, after the first laparoscopic partial hepatectomy, reported in 1992, the minimally invasive approach has been used increasingly in the management of hepatic diseases showing that despite several technical challenges, can obtain reduced operative blood loss, fewer early postoperative complications and shorter hospital stay with oncologic clearance and a survival rate si...
Chirurgia italiana
In the belief that the advantages stemming from a minimally invasive approach are significant, pa... more In the belief that the advantages stemming from a minimally invasive approach are significant, particularly in cirrhosis patients, we decided to apply this technique in the treatment of a group of patients suffering from HCC associated with cirrhosis. Sixteen patients (10 men, 6 women; mean age 60.1 years) underwent laparoscopic surgery for HCC associated with well compensated HCV-related liver cirrhosis (Child-Pugh class A; mean tumour size 2.9 cm). Seven of these lesions were located in the left liver and 9 in the right lobe. Laparoscopy was performed with a CO2 pneumoperitoneum (12-14 mmHg). The Pringle manoeuvre was not used. There was one conversion to laparotomy due to inadequate exposure. We performed 13 non-anatomical resections, 1 VI segmentectomy and 1 anatomical left lobectomy. None of the patients required blood transfusions. One patient died of severe respiratory distress syndrome on postoperative day 3. Major morbidity included 2 moderate postoperative ascites successf...
Open, Laparoscopic and Robotic Hepatic Transection, 2012
The introduction of new technological devices for efficient and fast hemostatic control during pa... more The introduction of new technological devices for efficient and fast hemostatic control during parenchymal transection has greatly enhanced the diffusion and safety of the laparoscopic approach in the field of liver surgery. In this chapter we review the usefulness of the ultrasonically activated device (USAD) for dissection of liver parenchyma during laparoscopic liver resection. Among the wide panorama of available devices, the USAD technology in our experience of 69 laparoscopic liver resections was revealed to be a useful tool in both the dissection and parenchymal transection phases. For instance, the Pringle maneuver was rarely needed to achieve a safe coagulating effect, even when prepared in case of major bleedings. USAD was demonstrated to be extremely efficient in mobilizing the liver by rapid and blood-less dissection of all suspending ligaments. Though there is a lack of data based on well-conducted controlled studies and further studies on a greater number of patients are needed, according to our experience, utilization of USAD may help to minimize blood loss during liver resection regardless of the condition of the liver, even in case of cirrhosis.
Updates in Surgery, 2013
After an initial period of scepticism, especially concerning technical and oncological problems, ... more After an initial period of scepticism, especially concerning technical and oncological problems, laparoscopic liver surgery (LLS) has become a feasible and safe technique. Over the past decade, the minimally invasive approach has been used increasingly in to manage hepatic diseases, showing that this technique in liver surgery, despite the technical challenges, reduces operative blood loss and results in fewer early postoperative complications, less postoperative analgesic drug consumption, and shorter hospital stay, with an oncologic clearance and a survival rate similar to that of open surgery [1–5]. Therefore, the place of laparoscopy in liver surgery is increasing, and many types of liver resections, including major hepatectomies, are now performed by laparoscopy in specialized centers [6–9]. Nevertheless, no international consensus on laparoscopic surgical management of liver lesions has been published, and no worldwide criteria exist for the indications for minimally invasive liver resection. Thus, there are no evidence-based criteria assisting the surgeon with management strategies for the laparoscopic treatment of liver tumors. For example, how large should the lesion be? Where should the lesion be located? Should we modify the well-accepted surgical indication only because we can perform a liver resection using a minimally invasive approach? Should we perform laparoscopic liver resection (LLR) only for benign lesions, or can we resect even malignant lesions by laparoscopy?
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2006
Surgical Endoscopy, 2009
Recurrence of cancer and the need for several surgical treatments are the Achilles&am... more Recurrence of cancer and the need for several surgical treatments are the Achilles' heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries. This report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery. The rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients. Laparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.
Journal of Hepato-Biliary-Pancreatic Surgery, 2006
Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery pr... more Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster. From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6-7.1 cm); all the lesions were localized in the anatomical left lobe (segments II-III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices. The mean operative time was 142 min (range, 120-180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days. The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.
Journal of Gastrointestinal Surgery, 2008
Hepatogastroenterology, 2011
Although multiple groups have reported initial success with single port laparoscopy, no consensus... more Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.
Journal of Hepato-Biliary-Pancreatic Surgery, 2009
Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the pro... more Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the procedure is gaining popularity. Minor laparoscopic resections have been widely reported. In contrast, major laparoscopic hepatectomy has been performed in only a limited number of cases. Hand-assisted laparoscopic liver surgery has been advocated in order to improve liver exposure and vascular control and increase the safety of the procedure. Transparenchymal en-bloc transection of the right portal triad has been reported to be safe and useful in open surgery. We describe a personal technique for hand-assisted right hemihepatectomy. With ultrasound guidance, the right hepatic pedicle is isolated intrahepatically and transected en bloc with a single firing of an endostapler. Parenchymal transection is carried out with ultrasonically activated or vessel-sealing devices together with endostaplers. The procedure was successfully accomplished in three patients. The Pringle maneuver was never performed. No intraoperative or postoperative complications occurred. This study is the first to report a technique of right hemihepatectomy that combines hand-assisted laparoscopy and an ultrasound-guided intrahepatic approach. This technique may be a useful option to simplify the operation, reduce operative time, and increase the safety of the procedure.