Abdominal Wall Surgery How Reimbursement Systems Can

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Editors
Dalila Patrizia Greco Elio Borgonovi
Day&Week Surgery Unit Department of Social and Political Sciences
Ospedale Niguarda Ca' Granda Bocconi University
Milano Milano
Italy Italy

ISBN 978-3-030-02425-3    ISBN 978-3-030-02426-0 (eBook)

https://doi.org/10.1007/978-3-030-02426-0

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Foreword

Over 100 years ago, Edoardo Bassini, a great pride of Italian surgery, asked whether
it was still necessary to argue about hernia surgery. Actually, since Hippocrates until
now, doctors have argued and debated about this topic and certainly will do so in the
next decades.
In the last 30 years, during the progression of my personal academic, scientific
and professional activities, I have had the honour and responsibility of the leader-
ship of the European Hernia Society, a great society involving world-renowned key
opinion leaders in hernia surgery that accounts for the largest part of the surgery
carried out all over the world.
Hand in hand with this scientific expansion, technological and material evolution
has been such as to merge the interest of patients, companies, media and especially
surgeons. And of course, all this represented a real challenge for the health organi-
zations in terms of cost/benefit ratio.
The fundamental objective in the surgery of the abdominal wall is the “restitutio
ad integrum”, that is to say a reconstruction as natural as possible, achieving at the
same time a perfect repair in the different districts, and a relapse rate as low as pos-
sible, trying of course to control the expenses.
But today, there is something new: the concept of “Quality of life” (QOL) has
become more and more important and appears in the most serious series as an
essential item, whose measurement is requested to the individual patient after sur-
gery; essentially, post-operative comfort for the recovery of normal life and work
habits, in some cases the improvement of sports performances, and finally the natu-
ral cosmetic appearance are no more considered as collateral objectives but rather as
essential ones.
For this reason, the concept of tailor-made surgery has been gradually developed,
and, together with the acquisition of our international guidelines, it must permeate
the training and the daily activity of surgeons who want to dedicate their profes-
sional life to this exciting journey.
This book has been realized thanks to the collaboration between surgeons and
economists: Prof. Elio Borgonovi is a world-renowned expert in health administration
and management and president of CERGAS, Bocconi University, Milan. Dr. Dalila
Patrizia Greco is a surgeon who, as many other colleagues, has been challenged for
years with the objective—as the same time difficult and beautiful—of obtaining the
maximum satisfaction for her patients. She is also a great expert in management and

v
vi Foreword

administration, this following the virtuous path of super-specialization: the book I

have the honour of presenting is the “summa” of their professional dedication.
I wish them and their collaborators the best of success with this book that has to
be recommended for all individuals interested in abdominal wall surgery.

Madrid, Spain Giampiero Campanelli

Past President of European Hernia Society
Preface

One of the main critical issues concerning health protection in modern systems is
the development of parallel worlds unable to speak and understand each other: med-
ical doctors, healthcare professionals, managers and policy-makers.
Doctors are focused on the development of scientific knowledge, clinical proce-
dures and techniques and on the relationship with patients. Managers are focused on
the functioning of hospitals and other structures delivering healthcare services and
on their organization and financial balance. Policy-makers are focused on the iden-
tification of general rules concerning professionals and structures and on resource
allocation.
The purpose of this book is to contribute to overcoming these crucial issues; it
stems from the fruitful collaboration of the Editors, who come, respectively, from
the world of abdominal wall surgery and from the world of management and health
policies protection systems. This preface is written adopting the “narrative
approach”, which is gradually growing in different research fields.
The cultural exchange started about 30 years ago when Elio Borgonovi launched
a master in economy and management (Ippocrate) addressed to medical doctors and
healthcare administrative professionals at SDA Bocconi (School of Management).
Health managers were the main audience, since clinicians’ activity was not yet
affected by the lack of resources, a problem that they have been facing in the last
decades. At that time, Dalila Patrizia Greco, young surgeon, was already interested
in abdominal wall surgery and in new models of care, such as Day Surgery, which
was considered a way to contain spending, at the same time increasing the quality
of service. She was convinced that in order to introduce a change, it was necessary
to prove its benefits. The performance schemes adopted at that time were simple and
simplicistic. Efficiency was emphasized independently from the clinical outcomes
and from the perceived quality from the patient’s point of view.
In a way, it was considered that new methods were automatically granting better
solutions to patients’ need, and hospital managers were focused on the comparison
between direct costs of inpatient versus outpatient surgery.
The young surgeon was convinced of the need to overcome this gap. She consid-
ered Ippocrate programme as the best place to start a dialogue not only among
researchers and teachers but also among people with heterogeneous professional
experiences. She believed that everyone could bring a different perspective in the
analysis of the reality.

vii
viii Preface

On the other hand, for an academic interested in economy and management, the
discussion with someone facing the requirements of the new medicine was both
challenging and useful. CERGAS and SDA were in fact adopting a bottom-up
approach (beginning from a problem to define actions and rules finalized to solve it)
that required a debate with front-line professionals to propose realistic and feasible
changes.
It was a fruitful meeting, which allowed them to exchange views on health sys-
tem and helped them to deal with the difficulties involved in the healthcare system
change. Several meetings, congresses and exchanges followed, enriching them and
helping surgeons to learn those management skills which were, at that point,
imperative.
The career development of the surgeon took her on the European Hernia Society
quality board, whose aim is to investigate the topics of a better surgical performance
and the possibility of developing tools to implement it. Different conditions are
essential to improve quality: surgeon’s skills, a well-organized system that allows to
build multidisciplinary teams and the availability of resources to acquire good and
appropriate technology.
The board has always claimed that abdominal wall surgery is penalized by inad-
equate reimbursement systems worldwide, above all by systems that require the
so-called “silos” financing (reimbursement of the single procedure/performance).
To be effective, abdominal wall surgery must produce advantages in terms of func-
tional recovery, in particular, reducing risk factors for recurrence and complications,
but these aspects are not considered by the “silos” reimbursement systems.
The board decided to study the consequences of the economy of the abdominal
wall surgery evolution. A phone call and a series of meetings between the surgeon
and the economist led to plan a conference where the surgeons had the task of
explaining in simple terms what abdominal wall surgery is (in the collective imagi-
nation, it generally means only inguinal hernia), while the economists had the task
of explaining to surgeons the functioning of complex organizations and how costs
are determined.
The conference was held under the auspices of the EHS quality board and of the
group of Italian surgeons who practise wall surgery and are affiliated with EHS
(ISHAWS), and it took place in the prestigious headquarters of SDA Bocconi in
January 2017.
During the conference, the delegates proposed to continue the discussion between
surgeons and economists, and they thought to realize this through a book that would
strengthen the communication channels between the two worlds.
It is difficult, if not impossible, for economists and management scholars to
understand the differences between the various methods and surgical techniques
and for surgeons to understand sophisticated aspects of economic analysis.
However, it was considered possible to identify a common ground that, avoiding
the most technical aspects of both fields, allowed to communicate and think together
about the improvement of this area of surgery.
In some cases, we found it interesting to exchange roles, planning contributions
in which surgeons talk about organizational aspects, criteria and requirements of
Preface ix

high specialization reference centres, while economists and management scholars

deal with the correlation between costs and benefits of medical research, clinical
evidence and health outcomes. This dialogue has later become a three-way discus-
sion, since it was considered useful, or even necessary, to involve users and patients’
associations, to represent the essential voice of people to whom the services are
addressed.
Many different readers could be enriched from reading this book: surgeons can
benefit from the knowledge of management principles, gaining incentives to find
suitable solutions to overcome the restrictions, thus considering management as an
opportunity, and not as an obstacle to their professional development and the adop-
tion of advanced technologies. Economists and management scholars can be helped
to better understand the complexity of abdominal wall surgery that, like other areas
of health protection, has its distinctive features, different from other services. Users
and patients’ associations may receive a help to raise awareness about the cost
impact of increasingly effective interventions.
To maintain a health system based on the principles of universality, solidarity and
impartiality, patients must realize that any right involving an economic interest,
such as health protection, can be concretely met also through their responsibility in
the prevention and the adoption of behaviours leading to a fast recovery after
surgery.
It was certainly a great effort to coordinate many people with different skills, but
our hope is to have opened a new way, to have proposed a model for collaboration
valid also for other areas of health protection. We thank everyone for accepting this
challenge and for their collaboration.

Milan, Italy Dalila Patrizia Greco

Elio Borgonovi
Contents

1 The Evolution of Surgery��������������������������������������������������������������������������   1

Elio Borgonovi and Dalila Patrizia Greco

Part I Abdominal Wall

2 Anatomy of the Abdominal Wall��������������������������������������������������������������   9
Cesare Stabilini and Ezio Gianetta
3 Clusters of Pathology and Interventions�������������������������������������������������� 21
Pier Luigi Ipponi and Diego Cuccurullo
4 Unit of Wall Surgery���������������������������������������������������������������������������������� 37
Francesco Gossetti, Linda D’Amore, Francesca Ceci, Lucia Bambi,
Elena Annesi, and Paolo Negro
5 Organization and Certification of Abdominal Wall Surgery ���������������� 43
Carla Rognoni
6 Biomaterials in Abdominal Wall Surgery������������������������������������������������ 51
Dalila Patrizia Greco and Claudia Abbati
7 Care Settings���������������������������������������������������������������������������������������������� 63
Dalila Patrizia Greco and Claudia Abbati
8 Preventing Incisional Hernias: Closure of Abdominal Wall,
Follow-Up in Abdominal Surgery������������������������������������������������������������ 71
Cesare Stabilini, Linda D’Amore, Elena Annesi, Lucia Bambi,
Paolo Negro, and Francesco Gossetti

Part II Economics
9 State-of-the-Art of Abdominal Wall Surgery in Italy:
Coding, Reimbursement, Hospitalisations and Expenditure
for Surgical Meshes������������������������������������������������������������������������������������ 87
Maria Caterina Cavallo, Giuditta Callea, and Rosanna Tarricone

xi
xii Contents

10 Presurgical Hidden Costs: Imaging, Assessment Clinic ������������������������ 105

Cristiano Sgrazzutti, Ilaria Vicentin, Alessandra Coppola,
and Angelo Vanzulli
11 Post-Surgical Hidden Cost: Neuralgia ���������������������������������������������������� 117
Paolo Notaro, Paolo Bocchi, Nicola Ladiana, and Claudia Abbati
12 Post-surgical Hidden Costs: Infections���������������������������������������������������� 127
Massimo Puoti, Dalila Patrizia Greco, Marco Merli,
and Claudia Abbati
13 Basic Principles of Health Technology Assessment,
Economic Evaluation, and Costing of Healthcare Programs���������������� 141
Rosanna Tarricone and Aleksandra Torbica
14 Economic Modeling and Budget Impact Analysis
in Abdominal Surgery: The Case of Mesh���������������������������������������������� 157
Carla Rognoni

Part III Outcomes
15 How to Measure Outcomes in Surgery���������������������������������������������������� 169
Graziano Pernazza and Enrico Pernazza
16 Present and Future of EBM in Inguinal Hernia Repair
and Abdominal Wall Reconstruction ������������������������������������������������������ 183
Umberto Bracale, Giovanni Merola, Cesare Stabilini, Maurizio
Sodo, and Giuseppe Cavallaro
17 Health Technology Assessment in Abdominal Wall Surgery������������������ 191
Valentina Beretta, Michele Tringali, and Antonio Marioni

Part IV Future Perspectives

18 Stakeholders’ Opinion ������������������������������������������������������������������������������ 201
Diego Orlando Freri
19 Evolution of Abdominal Wall Surgery
in Non-developed Countries���������������������������������������������������������������������� 207
Giampiero Campanelli, Piero Giovanni Bruni, Marta Cavalli,
and Francesca Martina Lombardo
20 How Social Patterns Affect the Development of Science
and Medicine���������������������������������������������������������������������������������������������� 213
Ivan Cavicchi

Part V Conclusions
21 Ferrying to the Future ������������������������������������������������������������������������������ 231
Elio Borgonovi and Dalila Patrizia Greco
The Evolution of Surgery
1
Elio Borgonovi and Dalila Patrizia Greco

The term surgery derives from the Greek words χέρι (hand) and ἔργον (work).
However, it is likely that surgical techniques first appeared before other medical
practices. Indeed, there are archeological findings dating back to the Paleolithic
which suggest that some sort of surgical activity was already being carried out, such
as trepanning. Furthermore, there is evidence that the Egyptians were capable of
performing highly specialized surgical techniques, with doctors benefiting from the
anatomical knowledge of embalmers. The first regulation of the medical profession
dates back to the Old Kingdom, whereas the world’s oldest depiction of a surgical
procedure—a circumcision—can be found at the entrance to the temple in Memphis.
The first example of regulating the practice of physicians and surgeons can be attrib-
uted to some of the laws found in the Code of Hammurabi (1792–1759 BC), which
provided for both monetary sanctions and corporal punishment in the event of medi-
cal errors.
In Europe, the “Hippocratic oath” was credited with bringing the medical prac-
tice out of the realm of magic and religion. The text attributed to Hippocrates (who
lived in Greece around 450 BC) represents the first code of conduct for the medical
profession, as well as the first time a distinction was made between physicians and
surgeons. Indeed, the latter were held in lower regard than the former, but they were
the only ones who could physically operate on patients.
After the barbarian invasions, medicine regressed during the Middle Ages. At
that point, the practice was largely based on Greek and Roman texts that had escaped

E. Borgonovi (*)
Department of Social and Political Sciences, Bocconi University, Milano, Italy
e-mail: [email protected]
D. P. Greco
Day&Week Surgery Unit, Ospedale Niguarda Ca' Granda, Milano, Italy
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

D. P. Greco, E. Borgonovi (eds.), Abdominal Wall Surgery,
https://doi.org/10.1007/978-3-030-02426-0_1
2 E. Borgonovi and D. P. Greco

destruction and which were now conserved in monasteries, making it the preroga-
tive of monks, who also provided healthcare and took in patients. The Hippocratic
distinction between physicians and surgeons still existed, with the former treating
what were considered to be internal problems and the latter operating on external
manifestations of disease. Surgeons mostly performed manual work, and indeed
they were often described as practici, but they were not necessarily poorly educated
people. Those with less training were the so-called barber-surgeons, who generally
performed bloodletting, treated wounds or carried out simple operations. The famed
medical school in Salerno (Schola Medica Salernitana) enjoyed its first period of
splendor against this backdrop, towards the end of the eleventh century. Lastly, there
were the so-called charlatans, commoners who lacked any formal training and who
would provide mostly ineffective remedies at a lower price than licensed
physicians.
As the study of human anatomy progressed, so too did surgery. Indeed, autopsies
carried out during the Middle Ages began to explore anatomy in addition to discov-
ering the cause of death. In any case, only with the revival of classical and humanist
studies in the Renaissance would the study of the human body come to be recog-
nized as an essential aid to surgery. In the sixteenth century, surgery was elevated to
a higher social and scientific status, achieving the same recognition reserved for
medicine. This was mainly thanks to the efforts of two major historical figures:
Paracelsus and Ambroise Paré. The latter was a member of the barber-surgeon guild,
but at the same time he worked at the Hôtel-Dieu in Paris, which was the area’s main
hospital. Paré started working as a surgeon in the French army, specializing in gun-
shot wounds. During the Damvillers campaign of 1552, he would perform the first
ligation of arteries during a leg amputation. The introduction of firearms would have
a significant impact on military surgery, leading to the development of revolutionary
techniques and new ways of treating the wounded.
That same period was also witness to an important evolution in the regulation
and supervision of the profession. Indeed, in 1540, two English guilds which up to
that point had been separate—the barbers and the surgeons—were united to form a
single Corporation (though each would retain its own coat of arms). The new charter
not only addressed the quality and duration of training, but also established that
surgeons could not perform the tasks of barbers, and that barbers would limit their
practice to pulling teeth (the Corporation would be dissolved in 1745, leading to the
formation of the independent Corporation of Surgeons; that body would then
become the Royal College of Surgeons in 1843, which still exists today). A new
decree in 1629 prohibited anyone from practicing medical professions unless they
had been specifically licensed to do so following an examination conducted by four
examiners, two of whom were to be master barber-surgeons.
As the Enlightenment unfolded and new ideas blossomed in all fields of human
knowledge, surgery too came to be recognized as an independent medical disci-
pline. Specialized texts written by renowned surgeons began to circulate, and the
first scientific societies dedicated specifically to surgery were established, such as
1 The Evolution of Surgery 3

the Académie de Chirurgie in Paris (1731) and the Royal College of Surgeons in
London (1800). Over the course of these centuries, surgeons, barber-surgeons, and
military surgeons would achieve different degrees of social status, with some recog-
nized as learned surgeons and others as untrained practitioners who learned on the
job. In any case, the three categories would unite towards the end of the eighteenth
century in most areas, and indeed French surgery was transformed from a craft guild
to a liberal guild in 1750.
These developments would eventually reach North America as well, albeit a bit
later on. While initially there were not so many physicians and professional sur-
geons in America, the great medical schools of the future would soon be founded at
America’s oldest universities, such as the University of Pennsylvania School of
Medicine in 1765 and Harvard Medical School. In his Discourse upon the Institution
of Medical School in America of 1765, John Morgan, the co-founder of the
University of Pennsylvania School of Medicine, made a conceptual distinction
between the practice of physic, surgery, and pharmacy.
Surgery was radically transformed towards the middle of the nineteenth century
with the introduction of anesthesia (Humphry Davy 1830, Horace Wells 1844,
Friedrich Trendelenburg with tracheal intubation 1881) and antisepsis (Holmes
1855, Semmelweis 1847, Lister 1865). These two practices led to an exponential
increase in the kinds of operations that could be carried out. Other innovations fol-
lowed, such as the introduction of surgical instruments to perform specific functions
(Kocher, Pean) as well as the first use of surgical gloves (Halstead 1890). At the
same time, there was a great change in the way patients were cared for, with women
playing an increasingly important role. This culminated with the Crimean War and
the nursing revolution led by Florence Nightingale. The technological innovation
began with the introduction of anesthesia, the first electrocautery device, respirators
and X-rays. At the beginning of the twenty-first century innovation in surgery was
accelerated thanks to hemorrhagic management by mono and bipolar electrosur-
gery, lasers, radiofrequency or surgical innovations as ablation, laparoscopy, robot-
ics, or innovative clinical management as preclinical assessment or ERAS. All of
this has helped dispel the myth that surgery depends solely on the ability of the
surgeon.
Just like medicine, as twentieth century surgery evolved, it came to encompass
various specializations (from general surgery to specialist surgery) as well as the use
of increasingly sophisticated, precise instruments and the presence of experts such
as surgeons, anesthesiologists, surgical technologists, nurses, and other operating
room technicians. What’s more, the duties of each professional must be coordi-
nated. In that regard, even the way a surgical team is coordinated has evolved, as the
more complex surgery has become, the more a positive outcome has come to depend
on the ability to work together and in harmony with the other professionals involved
(the concept of teamwork).
Moreover, the complexity of surgery increases even further when one considers
the hospitals and facilities in which it takes place. Indeed, the effectiveness of
4 E. Borgonovi and D. P. Greco

surgical procedures does not only depend on the knowledge, abilities, and actions
of the individual team members or on the technology at their disposal, but also on
how well the hospital is organized. This includes factors such as how the patient is
prepared for surgery, or whether the hospital has an area for postoperative care or
enough beds to accommodate the patient. There is more and more talk today about
the importance of surgical blocks and patient logistics, as well as of the instru-
ments and materials required for surgery. There is also another factor that has
emerged, especially in the early twenty-first century: namely, the difference
between “that which scientific knowledge and technology makes possible in the-
ory” and “that which can realistically be done.” On the one hand, this difference is
attributable to the varying degrees of organizational efficiency or inefficiency of a
given hospital; on the other hand, it depends on cost control and restrictions on
financial resources.
Thus, it can be said that the surgeon–patient relationship has evolved. As long
as the instruments were simple and rudimentary in nature, a successful surgical
procedure mostly depended on the surgeon’s skill. Later on, the surgeon’s—and
indeed the entire surgical team’s—ability to use technology came to influence the
effectiveness of surgery. The increasingly rapid evolution of technology has
introduced new dynamics to the practice of surgery, as well as the need for every
single surgical team to dialogue with other teams in order to share technology
and keep pace with innovation. And the complex nature of new technology means
that the concept of “team” must now include “teamwork,” meaning a group of
professionals with individual skills who work together to ensure success in sur-
gery. In other words, while a team is a group of experts who each have specific
duties, teamwork is a group of people who, despite having specific duties, learn
to work as an interdependent unit driven by a common goal: to resolve the
patient’s problem in the best way possible. In team-working non-technical skills
(organization, leadership, etc.) are as important as technical ones (surgical, anes-
thesiological, etc.).
In addition to these technological factors, another element has subsequently
come to influence the impact of a surgeon’s (and surgical team’s) skill on patient
outcomes: hospital efficiency. Indeed, several organizational factors contribute to
the creation of favorable conditions for a surgical team to meet patients’ needs
appropriately and effectively, including: good scheduling, satisfactory patient logis-
tics and materials management, suitable rooms, systems capable of supplying the
best materials in a timely fashion, and the availability of information.
Finally, the last link in the chain is the quality of policies, such as healthcare
funding levels, hospital reimbursement criteria for services rendered, and the priori-
tization of different groups of patients. Surgery today takes place within a “long
chain” that requires interdisciplinary knowledge. With changes in technology, orga-
nizational models, and healthcare settings (for example, intensive care units, sub-­
intensive care, etc.), as well as changes in funding methods and in the rules set forth
in health policies, available healthcare processes have become more complex. For
this reason, recovery outcomes have now come to be influenced by the sequence
outlined below:
1 The Evolution of Surgery 5

health policy

organization of health clinics or hospitals

surgeon surgical team technology patient

The increased complexity described in the flowchart above helps explain the
reason behind publishing this book. Indeed, this publication represents the conver-
gence of two fields of knowledge, skills and experiences, namely that of abdominal
wall surgeons and that of experts in economics, management, economic evalua-
tions, and health policy. There are a number of reasons why such a convergence is
so necessary and useful. First of all, there is a need to establish a “virtuous alliance”
in order to better deal with the restrictions that arise when healthcare demands and
the opportunities provided by scientific progress come up against limited resources.
After all, while knowledge is evolving at an exponential rate, economic growth rates
have been limited when compared to the past. Just look at China and the emerging
nations, which record an annual gross domestic product growth rate of 6–7%, while
the USA and Europe—even after the recovery period following the recession of
2007–2008—record a 2–3% annual growth rate.
Secondly, an alliance between the two cultures will foster synergy and thus pre-
vent vicious circles from arising when the two worlds are not able to dialogue with
each other. If abdominal surgeons, like all other healthcare professionals, continue
to support the principle of “providing everybody with the best”—which is under-
standable from a theoretical point of view—while managers and experts in eco-
nomic evaluations focus their attention on restrictions and on the “impossibility of
providing everybody with the best,” then it is a waste of time and energy that would
be better spent on the patient. However, if the two sides can understand each other
and work together, it will be possible to find solutions that “provide more (quantity
and quality to meet healthcare needs) with less (resources).” Such an alliance will
lead to a better understanding of why health clinics and hospitals conduct them-
selves the way they do, as well as the reasoning behind health policy (on a regional
and national level, and in terms of public finance). Indeed, all of these factors influ-
ence the healthcare context in a way that cannot be ignored.
Thirdly, it must be emphasized that the possibility of achieving more with less
depends on the efforts of the two protagonists involved. The surgeon (and the
healthcare professional in general) is focused on doing right by the individual—an
approach that is best expressed as the “pursuit of the optimal solution for each
6 E. Borgonovi and D. P. Greco

patient.” The expert in economic evaluations, the business manager, the health
policy-­maker, is focused on doing right by the population, or at least guaranteeing
equity among social groups or groups of patients that have different healthcare
needs. The surgeon/doctor/healthcare professional is in direct contact with the
patient: when their approach prevails, they come up with optimal solutions for each
phase of the patient’s care, but only for those patients who have access to such ser-
vices. Meanwhile, those who have no such access due to long waiting lists or lack
of funding do not receive effective care. If the economic evaluations expert/business
manager/health policy-maker’s approach prevails, then that leads to solutions which
on a theoretical level might indeed aim to guarantee a general level of equity, but in
practice often turn into restrictions and inflexible rules that prevent patients from
receiving appropriate, effective care. The two sides must be able to dialogue and
establish a common ground for discussion: only then will it be possible to achieve
better optimal solutions for individual patients and general equity (or at least, less
inequality) for the population.
Fourthly, a lack of mutual understanding drives a wedge between “wanting to”
and actually “being able to,” because while scientific knowledge and available tech-
nology might make a certain solution theoretically possible, too often it cannot be
done due to an inability to overcome the restrictions that stand in the way. To bridge
this gap between “wanting to” and “being able to,” both sides need to further develop
their “knowledge” (i.e., the surgeon must better understand issues concerning eco-
nomic evaluation and healthcare organization, management, and policy, while
experts in these fields must better understand the issues facing those who have daily
contact with patients) and their “know-how” (i.e., both sides need to work together
to find realistic, concrete, applicable solutions).
 Part I
Abdominal Wall
Anatomy of the Abdominal Wall
2
Cesare Stabilini and Ezio Gianetta

2.1 General Appearance

2.1.1 Superficial Layers

The superficial layers of the anterolateral abdominal wall include the skin, the sub-
cutaneous tissue divided by Camper’s and Scarpa’s fascia. It contains lymphatic
vessels and arteriovenous structures.

2.1.2 Myoaponeurotic Structures

The muscular components of the abdomen are represented by the two rectal muscles
in central positions and a layer of three large lateral muscles namely external
oblique, internal oblique, and transversus abdominis. This muscular complex is
contained in a system of interconnected dense connective fibers which create the
aponeurotical layers of the abdominal wall.
The rectus abdominis muscle (RA) has a proximal insertion in the V–VI–VII
costal cartilage and xyphoid process, distally the muscle reaches the pubic crest.
The RA has three transversal tendinous inscriptions which adhere firmly to the ante-
rior rectus sheath as a result of the embryonal development. Anteriorly and caudally
to the rectus muscle, inside of its sheath, the pyramidalis muscle exerts a tensive
effect on the RA with its insertions on the pubic crest and linea alba.
The external oblique (EO) muscle takes its origin from the last eight ribs inter-
mingling with latissimus dorsi and serratus anterior. The muscle has both a muscu-
lar and an aponeurotic part, the transition line is vertical downward medially to the
emiclavear line, and below the anterosuperior iliac spine (ASIS) the muscle is

C. Stabilini (*) · E. Gianetta

Department of Surgery, University of Genoa School of Medicine, Genoa, Italy
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 9

D. P. Greco, E. Borgonovi (eds.), Abdominal Wall Surgery,
https://doi.org/10.1007/978-3-030-02426-0_2