A thorough understanding of abdominal wall anatomy is foundamental to safe and effective hernia repair. The complex and highly organized arrangement of muscular, fascial, and neurovascular structures and their relationships demands careful analysis, particularly in the context of modern surgical techniques such as component separation and minimally invasive approaches like extended totally extraperitoneal and robotic transversus abdominis release. This chapter will provide a comprehensive, clinically oriented review of the functional anatomy of the abdominal wall, progressing sistematically from the superficial layers to the posterior rectus sheath and transversalis fascia. Particular attention is given to the anatomical planes and potential spaces that are critical to both open and minimal invasive surgical approaches. Key surgical landmarks, including the semilunar line, arcuate line, and major neurovascular bundles, are described in detail, along with common anatomical variations that may influence operative strategy and surgical decision-making. An emphasis is placed on the biomechanical role of each abdominal wall layer and its relevance to defect formation, hernia classification, and reconstructive planning. Understanding these principles allows for more accurate selection of surgical techniques, improved restoration of abdominal wall function, and reduced rates of recurrence and postoperative morbidity. By integrating anatomical knowledge with practical surgical application, this chapter aims to serve as a valuable resource for both general and specialist surgeons involved in abdominal wall reconstruction. Illustrative diagrams and intraoperative images will support the anatomical descriptions, enhancing both didactic clarity and practical relevance for clinical decision-making.

According to the most recent guidelines, uncomplicated acute appendicitis could be treated conservatively using broad-spectrum antibiotics, but if radiological signs of appendix rupture are present, appendectomy should be considered as first-line treatment. There is limited evidence in literature regarding the non-operative management of complicated acute appendicitis, particularly in the subset of patients with Crohn's disease. Intestinal and contrast-enhanced ultrasound appear pivotal to both diagnosing complications and promptly identifying the non-responding patients. We describe two cases of complicated acute appendicitis, successfully treated with broad-spectrum antibiotic therapy and tight monitoring with both intestinal and contrast-enhanced ultrasound, in patients with Crohn's disease.

Enhanced Recovery After Surgery (ERAS) pathways safely reduce length of stay (LOS) and resource use in many surgical fields, but their economic impact in thyroidectomy within the Italian National Health Service (SSN) is unclear, particularly under Diagnosis-Related Group (DRG) rules that penalize early discharge. A decision-analytic model compared an ERAS-inspired thyroidectomy pathway—same-day discharge after hemithyroidectomy and 24-hour discharge after total thyroidectomy—with a conventional DRG-driven pathway based on ≥2 postoperative inpatient days. The analysis adopted a hospital/provider perspective over 30 days, using data from a high-volume endocrine surgery unit and contemporary ERAS literature. Outcomes included LOS, postoperative complications, 30-day readmissions, direct hospital costs, and contribution margin under current SSN tariffs (including early-discharge penalties) and under a neutral reimbursement scenario. In hemithyroidectomy (400 cases/year), ERAS reduced mean LOS from 2.6 to 0.33 days (–2.27 days; p<0.001), freeing 908 bed-days annually and lowering variable costs by €1,332 per patient, without increasing complications or readmissions. Despite a 30

AIM: The surgical management of colonic Crohn’s disease (CD) remains controversial, with segmental resections possibly associated with a higher rate of recurrence and postoperative complications, while total proctocolectomy reduces recurrence but increases the risk of permanent stoma formation. This study compares surgical outcomes and complications in CD patients undergoing colonic resections (any colectomy with or without concomitant ileal/ileocaecal surgery) vs non-colonic resections (ileal or ileocaecal resections and/or small-bowel strictureplasties without colectomy), with particular emphasis on intra-abdominal septic complications (IASC), non-IASC events, and length of stay (LOS) in hospital. METHODS: This monocentric observational study analysed consecutive adult patients with histologically confirmed CD who underwent intestinal surgery between January 2012 and April 2024 at Luigi Sacco University Hospital. Patients were divided into two groups according to the index operation. Group A included patients undergoing colonic resection, with or without concomitant ileal or ileocaecal resections and/or small-bowel strictureplasties. Group B included patients undergoing ileal or ileocaecal resection and/or small-bowel strictureplasties without any associated colonic resection. Outcomes included 30-day postoperative complications, LOS, and readmission rates. Statistical analysis was performed using chi-square, Wilcoxon rank-sum tests, and regression models. RESULTS: Of 461 patients, 90 (19.5%) underwent colonic resections (Group A), while 371 (80.5%) had non-colonic resections (Group B). Overall, complications occurred in 36.2% of patients, with significantly higher rates in Group A than in Group B (48.9% vs 33.2%; p = 0.005). IASC were more frequent in Group A (18 out of 90 patients, 20.0%) than in Group B (37 out of 371 patients, 10.0%) (p = 0.008). The median LOS was 11 days overall, with a statistically significant difference between the groups (Group A: 12 days; Group B: 11 days, p = 0.012). In addition, we observed a significantly higher 30-day reoperation rate in Group A compared with Group B (14.4% vs 6.5%; p = 0.012). Thirty-day readmission rates were low and did not differ significantly between the groups (3.3% vs 1.3%, p = 0.365). Colonic resection, disease phenotype, and American Society of Anesthesiologists score were identified as independent risk factors for postoperative complications and prolonged LOS. There were no significant differences in the 30-day readmission rates among the groups, and no 30-day mortality cases were observed. CONCLUSIONS: In this large single-centre cohort, colonic resections were associated with higher postoperative complication rates, increased IASC and longer LOS compared with non-colonic resections. These differences likely reflect greater baseline disease complexity and operative burden in patients requiring colonic resection, rather than a causal effect of the resection site alone, highlighting the need for individualised, phenotype-informed surgical decision-making. Further multicentre research is recommended to refine the surgical management of colonic CD.

This study aims to provide a meta-analysis of randomized controlled trials (RCTs) comparing non-operative management (NOM) and operative management (OM) in a pediatric population with uncomplicated acute appendicitis. A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL from inception to June 2024. Only randomized controlled trials (RCTs) were included, excluding studies involving adult patients and/or participants with complicated appendicitis. The variables considered were treatment complications, treatment efficacy during index admission and one-year follow-up, length of hospital stay (LOS), quality of life, and presence of appendicoliths. Three RCTs involving 269 participants (134 antibiotics/135 appendectomy) were included. There was no statistically significant difference between the two treatments in terms of complication risk (combined RD = − 0.03; 95

Intussusception is a rare cause of intestinal obstruction. In adults, it is often secondary to an underlying pathology. Imaging plays a central role in the diagnosis. Surgical intervention is the treatment of choice when bowel obstruction occurs. The goal of surgery is both therapeutic and diagnostic, allowing for resection and pathological evaluation. This case of a 76-year-old female shows that early recognition and prompt surgery are crucial for a favorable outcome. The patient exhibited symptoms of bowel obstruction. The computed tomography scan clearly demonstrated intussusception of the terminal ileum into the cecum. The patient underwent urgent laparoscopic right hemicolectomy with extracorporeal anastomosis. Histological findings: intussusception with a tubulovillous adenoma with low-grade dysplasia and without invasive features. In this case, an underlying potentially malignant evolving condition was discovered and removed. In conclusion, early recognition and intervention are key to improving outcomes in patients with intussusception and intestinal obstruction signs.

Post-traumatic diaphragmatic hernia is a rare and potentially life-threatening condition that can occur after blunt or penetrating trauma. Delayed presentations are uncommon, but can lead to serious complications, such as bowel obstruction. We report a case of a 31-year-old male patient who presented five years after a thoracic trauma with symptoms of intestinal obstruction and was diagnosed with a delayed post-traumatic diaphragmatic hernia. The diagnosis was made through contrast-enhanced computed tomography scan, and the patient underwent laparoscopic repair with mesh reinforcement. This case highlights the importance of considering diaphragmatic hernia in the differential diagnosis of patients with a history of trauma, even if the presentation is delayed. Prompt diagnosis and surgical intervention are crucial to prevent serious complications and improve patient outcomes. This study adds to the existing literature on traumatic diaphragmatic hernias, emphasizing the need for enhanced clinical awareness, interdisciplinary cooperation, and surgical repair.

Abstract Background The main challenge in surgical treatment for terminal ileal Crohn’s Disease is represented by the significant recurrence at the anastomotic site after ileocecal resection.1 Latero-lateral anastomosis is frequently performed in this kind of surgery because of its characteristics of ductility and reproducibility; the Kono-S anastomosis - characterized by a supporting structure and a wider lumen - was recently introduced to reduce the risk of recurrence.2 Several studies indicate a reduction in recurrence and complications, but evidence remains limited and controversial, particularly for long-term follow-up.3, 4 Methods This monocentric study included 30 Crohn’s patients admitted in a Tertiary Care IBD Centre in Milan between 2023 and 2024, comparing 10 patients who underwent Kono-S anastomosis with 20 who underwent latero-lateral isoperistaltic anastomosis. Both groups included patients with ileal stenosing Crohn’s Disease (B2-L1 according to the Montreal classification). Surgery was performed with a mini-invasive approach, and the selected patients were naïve to abdominal surgery for Crohn’s. Results Preoperative variables considered included the mean age of the patients, BMI, sex, smoking habit, Charlson Comorbidity Index (CCI), ASA score, duration of illness at the time of surgery. Regarding postoperative data, blood glucose showed significantly higher mean values in the Kono-S group (125.1 ± 26.3 mg/dL) than in the latero-lateral group (105.7 ± 20.1 mg/dL). About postoperative complications, our data shows that one patient in the Kono-S group developed perianastomotic abscess, one other needed blood transfusion for anaemia and one patient underwent reintervention for anastomotic bleeding (Clavien-Dindo 3b). In the latero-lateral group, two patients developed anaemia (without needing blood transfusion) and other two needed blood transfusion; finally, one patient developed anastomotic leak requiring reintervention. The mortality was nil. Other postoperative data (such as duration of surgery, C-Reactive Protein in 1 and 3 postoperative days, number of days before gas flatus and stool canalization, fever, assumption of diet, number of days before discharge, re-admission and re-intervention) were analysed (reported in the attached table). Conclusion Our results indicate an overlap between the two techniques in terms of safety and perioperative management, with a comparable rate of major complications such as anastomotic dehiscence (0% in the Kono-S group versus 5% in the latero-lateral group) or readmission. However, the small sample size limits the scope of the results and suggests the need for further studies to assess the actual impact of the Kono-S technique on long-term recurrence. References 1.Nos P, Domenech E. Postoperative Crohn’s disease recurrence: a practical approach. World J Gastroenterol 2008;14(36):5540–5548. 2.Kono T, Fichera A, Maeda K, et al. Kono-S anastomosis for surgical prophylaxis of anastomotic recurrence in Crohn’s disease: an International Multicenter Study. J Gastrointest Surg 2016;20 (04):783–790. 3.Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn’s disease: a systematic review. Colorectal Dis. 2021 Jan;23(1):7-17. 4.Baloyiannis I, Perivoliotis K, Sarakatsianou C, Chatzinikolaou C, Tzovaras G. The Reduction of Anastomosis-Related Morbidity Using the Kono-S Anastomosis in Patients with Crohn’s Disease: A Meta-Analysis. J Clin Med. 2024 Apr 23;13(9):2461.

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and Ulcerative Colitis (UC), is characterized by chronic inflammation of the gastrointestinal tract, and its long-standing course significantly elevates the risk of colorectal cancer (CRC), primarily arising from dysplastic lesions. While regular surveillance by colonoscopy is well established for UC patients, guidelines for CD remain uncertain. Computed Tomographic Colonography (CTC) offers a minimally invasive alternative for evaluating the colon, particularly in cases where colonoscopy is incomplete or contraindicated. Although not commonly utilized in IBD management, CTC provides substantial advantages in identifying complications such as fistulas, strictures, and colonic neoplasms. Additionally, it offers anatomical detail, which is crucial for surgical planning and decision-making. In this review we aim to demonstrate the usefulness of CTC in selected IBD cases, particularly in patients for whom colonoscopy is not feasible, and to show how its integration into clinical practice enhances decision-making and provides crucial insights into disease complications.

Graduate medical education (GME) programmes are integral to healthcare systems, providing clinical manpower through medical residents whose compensation is externally funded in Italy. The financial impact of resident integration on public hospital budgets, particularly amid rising healthcare expenditures, remains poorly quantified. We conducted a deterministic 12-month Budget Impact Analysis from the hospital perspective (EUR 2024), comparing an attending-only workforce with a resident-integrated configuration. Inputs included attending full-cost FTE (salary + employer on-costs), resident productivity by setting, supervision shares (translated into effective attending FTE), and departmental workload. Uncertainty was addressed through Monte Carlo probabilistic sensitivity analysis. This Budget Impact Analysis (hospital perspective; EUR 2024; 12-month horizon) found that integrating Ministry-funded residents reduced annual personnel expenditure by 40–50

Heterotopic pancreas (HP) is a rare condition where pancreatic tissue is found outside its usual location, usually within the gastrointestinal tract. While typically asymptomatic, HP can cause complications like gastrointestinal bleeding and intussusception, especially in adults, posing diagnostic and therapeutic challenges. A 31-year-old male presented with severe abdominal pain, nausea, and vomiting. Initial imaging revealed significant ileal and cecal wall thickening. Despite antibiotic therapy, his condition worsened, necessitating exploratory laparotomy. Intraoperative findings showed ileal intussusception near the cecum, leading to ileocecal resection and ileo-colic anastomosis. Pathological examination confirmed HP as the cause of intussusception. This case underscores the importance of considering HP in adult intussusception. Timely surgical intervention is critical to prevent severe complications. At a two-year follow-up, he remained symptom-free, highlighting the necessity for prompt diagnosis and management.

Colorectal cancer (CRC) remains challenging to diagnose, necessitating the identification of a noninvasive biomarker that can differentiate it from other conditions such as inflammatory bowel diseases (IBD) and diverticular disease (DD). Raman spectroscopy (RS) stands out as a promising technique for monitoring blood biochemical profiles, with the potential to identify distinct signatures identifying CRC subjects. We performed RS analysis on dried plasma from 120 subjects: 32 CRC patients, 37 IBD patients, 20 DD patients, and 31 healthy controls. We also conducted longitudinal studies of CRC patient's postsurgery to monitor the spectral changes over time. We identified six spectral features that showed significant differences between CRC and non-CRC patients, corresponding to tryptophan, tyrosine, phenylalanine, lipids, carotenoids, and disulfide bridges. These features enabled the classification of CRC patients with an accuracy of 87.5%. Moreover, longitudinal analysis revealed that the spectral differences normalized over 6 months after surgery, indicating their association with the presence of the disease. Our study demonstrates the potential of RS to identify specific biomolecular signatures related to CRC. These results suggest that RS could be a novel screening and monitoring tool, providing valuable insights for the development of noninvasive and accurate diagnostic methods for CRC.

Traditionally, radical prostatectomy (RP) has been considered a contraindication to minimally invasive inguinal hernia repair. Purpose of this systematic review was to examine the current evidence and outcomes of minimally invasive inguinal hernia repair after RP. Web of Science, PubMed, and EMBASE data sets were consulted. Laparoscopic transabdominal preperitoneal repair (TAPP), robotic TAPP (r-TAPP), and totally extraperitoneal (TEP) repair were included. Overall, 4655 patients (16 studies) undergoing TAPP, r-TAPP, and TEP inguinal hernia repair after RP were included. The age of the patients ranged from 35 to 85 years. Open (49.1

Abstract Background Crohn’s disease (CD) affecting the upper gastrointestinal (GI) tract is a rare condition, leading to a scarcity of information regarding its diagnosis, surgical treatment, and adjuvant therapy. The JUICE study aimed to conduct a surgical audit of duodeno-jejuno-ileal CD across 11 European IBD Referral Centres. Methods The study included all the consecutive, non-selected patients undergoing surgery for upper-GI CD between January 2010 and December 2022. Patients with synchronous ileal and colonic locations were included, while those with previous upper-GI CD surgery or multiple surgeries for ileo-colic CD were excluded. Univariate and multivariate analyses of 120 variables, covering pre-operative characteristics, intra-operative findings, and post-operative follow-up, were conducted. Results The study encompassed 279 patients, with a male/female ratio of 2.2. The average age at diagnosis was 30±14 years, and the disease duration was 11±10 years. The Montreal Classification revealed A1 15.4%, A2 61.3%, A3 23.3%; L1+L4 34.4%, L2+L4 4%, L3+L4 26.9%, isolated L4 34%; B1 1.8%, B2 67.4%, B3 30.8%; perianal location 19.4%. BMI averaged 21±3. Preoperative nutritional support was necessary in 50.5%. MRI-enterography was the predominant preoperative examination (86.7%). Comorbidities were present in 24.7%, with 61% having an ASA score >1. In the 30 days pre-surgery, 16.8% used steroids, 41.2% received biologicals, with 24.6% on combined (biologicals + steroids) therapy. Video-assisted approach was used in 70%, with a 5.1% conversion rate. Intraoperative staging revealed 1334 locations treated with 247 resections, 500 strictureplasties, 12 bypasses, and 53 concomitant colonic resections. Entero-enteric fistulas and intra-abdominal abscesses were present in 29% and 14%. Patients with thickened mesentery, wrapping fat, and lymph node enlargement were 50.8%, 38.7%, and 50.8%, respectively. Mortality was 1%, Clavien-Dindo grade 3 and 4 complication rate 11.1%. Hospital stay averaged 10±6 days; 90-day readmission was 3.2%. B3 behaviour, smoking, preoperative malnutrition, and preoperative biological therapy increased postoperative complication risk (p=0.01). 10-year Kaplan-Meier surgical recurrence rate was 23%, reduced to 11% with early and continuous post-op biologic treatment compared to late treatment or suspension (60% - Log-Rank p<0.0001). Conclusion This is by far the largest series of upper-GI CD ever studied, depicting a little known, complex, technically demanding sub-group of patients. Preoperative optimization, focusing on preoperative nutritional status and therapy, is crucial to reduce complication risk. Early-onset post-operative biological therapy seems to significantly reduce long-term surgical recurrence.

BackgroundRecurrent non-stenotic cholangitis (NSC) is a difficult-to-treat complication after hepaticojejunostomy (HJ) leading to multiple hospital admissions. The optimal treatment strategy is unclear as a systematic review is lacking.MethodsA systematic review was performed including studies detailing treatment strategies and outcomes for recurrent NSC in patients with a surgical HJ in PubMed, Embase, and Cochrane Library (inception – September 2023). Primary outcome was resolution of NSC as defined by the included studies.ResultsOverall, 72 patients with recurrent NSC after HJ were included from seven retrospective studies. The rate of recurrent NSC (specified in five studies) was 4% (46/1143 HJs). Diagnosis of NSC was mostly made after excluding HJ stenosis and assessing bile reflux. Initial treatment consisted of short-course antibiotics for all patients. Second step treatment consisted of prolonged antibiotic therapy (n=10, 13.8%). Third step treatment consisted of surgery (n=9, n=12.5%); mostly lengthening of the biliary loop. Together, the overall reported resolution-rate of recurrent NSC was 66.6% (n=48).DiscussionA ‘step-up approach’ may be effective in two-thirds of patients with recurrent NSC after HJ, starting with short-course antibiotics, and eventually adding prolonged antibiotic therapy and, ultimately, surgery aimed at preventing intestinal content and food reflux. Prospective studies are needed.

Background The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis. Methods A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs. Results Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61—1.04, P = 0.07, I 2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I 2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I 2 = 81%) participants. There was no difference in LOS (mean difference − 0.58 days 95% confidence interval − 1.59 to 0.43, p = 0.26, I 2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence. Conclusions As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes.

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BACKGROUND: Introduction of diagnostic tests for cerebral concussion detection in head trauma must constitute a milestone in sporting events in order to immediately address the management and therapeutic process of the injured athlete, as well as the return-to-play in safety.METHODS: During activity in Contact Sports (i.e. Rugby, Boxing, American Football, Football, Ice Hockey) or in individual Sports (Motor Sports, Cycling, Alpine Skiing, Bobsleigh, Skeleton) where there is a high risk of head trauma and consequent cerebral concussion, currently in Italy there is no other diagnostic method on playground than direct observation of the traumatic event by the Team Doctor and the subsequent objective examination of the athlete combined with anamnestic data.RESULTS: The most obvious symptom of concussion is loss of consciousness, although most injured athletes experience other symptoms and signs such as headache, nausea and vomiting, dizziness, postural balance disturbances, confusion with lightheadedness or numbness, retrograde amnesia or anterograde, diplopia and photophobia. Sometimes the symptoms are absent or trivial and the injury is underestimated with possible subsequent immediate and deferred serious consequences as Second Impact Syndrome.CONCLUSIONS: Introduction of biomarkers test of head trauma and consequent concussion is an American reality for the National Football League in the 2023-2024 championship. Estimates of the incidence of sport related concussion in the United States vary from underestimates by 200,000 cases up to a conceivable number of 3,800,000. When occurs a fatal outcome the fatal concussion was mainly subsequent to a previous undiagnosed event (SIS): data from the Centers for Disease Control and Prevention. In Italy there are no certain data on this matter. An approximate estimate, calculated on data from Emilia Romagna, assumes around 120,000 cases per year in line with the American data compared to the Italian population. To complete validated concussion protocols, it is necessary to introduce reliable biomarkers in order to manage the athlete’s injury and to obtain a diagnostic and therapeutic gold standard, as well for return-to-play of the athlete.

BACKGROUND:Laparoscopic cholecystectomy (LapC) is one of the most frequently performed surgical procedures worldwide. Reaching technical competency in performing LapC is considered one essential task for young surgeons. Investigating the learning curve for LapC (LC-LapC) may provide important information regarding the learning process and guide the training pathway of residents, improving educational outcomes. The present study aimed to investigate LC-LapC among general surgery residents (GSRs).METHODS:Operative surgical reports of consecutive patients undergoing LapC performed by GSRs attending the General Surgery Residency Program at the University of Milan were analysed. Data on patient- and surgery-related variables were obtained from the ICD-9-CM diagnosis codes and gathered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis.RESULTS:340 patients operated by 6 GSRs were collected. The CUSUM and RA-CUSUM graphs based on surgical failures allowed to distinguish two defined phases for all GSRs: an initial phase ending at the peak, so-called learning phase, followed by a phase in which there was a significant decrease in failure incidence, so-called proficiency phase. The learning phase was completed for all GSRs at most within 25 procedures, but the trend of the curves and the number of procedures needed to achieve technical competency varied among operators ranging between 7 and 25.CONCLUSIONS:The present study suggested that at most 25 procedures might be sufficient to acquire technical competency in LapC. The variability in the number of procedures needed to complete the LC, ranging between 7 and 25, could be due to the heterogeneous scenarios in which LapC was performed, and deserves to be investigated through a prospective study involving a larger number of GSRs and institutions.