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colon cancer, colon cancer, colon anatomy
Colon cancer: minimally invasive surgery in Chivasso

Colon cancer is among the most frequent cancers in our country, ranking third (after prostate and lung ) in men and even second (after breast) in women. In 2019, new colon cancer diagnoses expected in Italy are 49,000 (27,000 men, 22,000 women). Mortality, thanks in part to screening programs, has been steadily declining for years. Early detection makes it possible to arrive at a high cure rate for this cancer; now genetic tests on blood and stool are beginning to be available that can identify the risk of developing colon cancer very early. This is tato more important as, in recent years, the average age at which colon cancer appears has lowered.

Treatment of colon cancer is surgical, and consists of removing the tumor itself then reconstructing the integrity of the colon in order to allow stool transit.

colon cancer, colon cancer, colon anatomy
Anatomy of the colon

The colon, from an anatomic-surgical point of view, is divided into regions: cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum; cancer can affect any of these districts. The clinical manifestations of colon cancer vary depending on which district is affected: cancer of the cecum and ascending colon, for example, is less frequent, more typical of the elderly, and most often manifests with anemia; cancer of the descending colon or sigmoid colon is more frequent and most often presents with symptoms of bowel obstruction and/or rectorrhagia (bleeding from the anus).

Today, the gold standard for this surgery is laparoscopic surgery: whereas until a few years ago it was necessary to perform a laparotomy, that is, a large cut from the sternum to the pubis, to gain access to the colon, today, the same surgery can be performed through 3-4 small holes in the abdominal wall, and a minimal cut, usually above the pubis, to extract the tumor from the abdomen once it has been removed.

Colon cancer, colon cancer, laparoscopic surgery
Laparoscopic hemicolectomy surgery

L'laparoscopic removal of the colon, especially of the cecum and ascending colon, is a technically complex operation: this is why many surgeons do not perform it, continuing to perform the traditional cut. However, in experienced hands, it ensures a complete removal of the tumor and lymph nodes (possible site of metastasis), very significantly reducing postoperative pain and accelerating the functional recovery of patients and their return to home and their activities: typically, a patient undergoing laparotomic (i.e., traditional cut) removal of colon cancer remains hospitalized 7-10 days, while for a patient whose colon cancer has been removed laparoscopically, the hospital stay is 4-5 days.

colon cancer, colon cancer, laparotomy, laparotomy scar
The laparotomic scar after removal of colon cancer

Laparotomy leaves a large scar and can itself be the cause of disease, typically the formation of a laparocele, which is an abdominal hernia that appears on the laparotomy scar. These are often very large hernias, which can only be repaired once a suitable period of time has elapsed after the tumor has been removed, with surgery that is not infrequently very demanding on the patient-even more complex than the removal of colon cancer. In such cases, the patient's quality of life deteriorates significantly: abdominal pain, back pain, breathing difficulties may appear, as well as all the typical complications of laparocele, such as incarceration and very dangerous stricture.

In contrast, the risk of laparocele is almost zero when the patient is operated on laparoscopically.

colon cancer, colon cancer, laparoscopic scarring, laparoscopy
Typical appearance of scars after laparoscopic surgery

In our hospital in Chivasso, I perform laparoscopic surgeries for the removal of colon cancer (bothright hemicolectomy, in cases of cancer of the cecum, ascending colon, hepatic flexure, and first portion of the transverse colon; andleft hemicolectomy, for cancer of the descending colon, sigmoid colon, splenic flexure, and second portion of the transverse colon); in particular, I was the first, and currently I am still the only one, to perform right hemicolectomy laparoscopically.

For more information you can reach me by filling out the form below, emailing info@cuccomarinomd.com, sending me a WhatsApp message or calling 01119903768.



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Dr. Salvatore Cuccomarino
Medical Surgeon Specialist in General Surgery
Digestive system surgery, laparoscopic colon surgery, endoscopic rectus diastasis (REPA) and laparocele surgery, hernia surgery, coloproctology
Studio De Medica - Galileo Ferraris course 12
Phone 01119903768
hemorrhoids, anal fissure, proctology, proctologist in turin, cuccomarino
Hemorrhoids and fissures are treated in the outpatient clinic

hemorrhoids, anal fissureHemorrhoids and anal fissures? Treatment most often is outpatient. These are difficult times, we all know. The ongoing epidemic has forced all hospitals to suspend outpatient visits and surgical activity, except in emergencies, to make room for infected patients. However, life goes on for everyone, and the health problems that worried us before continue to worry us now.

Not everything can be treated in an outpatient setting; however, for several proctologic conditions, quite a bit can be done. For example, the hemorrhoids and anal fissures can be treated on an outpatient basis: the second- and third-degree hemorrhoids with the procedures of elastic ligation and sclerosis, and the anal fissures with topical nitroglycerin and lidocaine treatments and, possibly, after confirming the pressure values of the anal sphincter system with manometry, with infiltrations of botulinum toxin. These are painless, simple and inexpensive methods, which in most cases effectively resolve these bothersome problems.

Hemorrhoids and anal fissures are not serious health problems, but they certainly can worsen the quality of life. Treating them on an outpatient basis is possible, not dangerous and, in the hands of a good proctologist, simple and inexpensive. For this, we remain at your disposal at our office in Chivasso, De Medica, Corso Galileo Ferraris 12 F, telephone 01119903768 and inTurin, in the offices of Pinna Pintor Clinic, via Amerigo Vespucci 61, telephone 0115802100. To contact us, our Facebook page or the following contact form is also available:

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Dr. Salvatore Cuccomarino
Medical Surgeon Specialist in General Surgery
Coloproctology, Surgical gastroenterology, Abdominal wall surgery, Laparoscopic surgery
Corso Galileo Ferraris 12 F
Phone 0110438161
hemorrhoids, anal fissure
I have hemorrhoids - But WHY do I have them???

Two lines on the causes of internal hemorrhoids.

Obviously, all things (including the human organism) are made to perform a certain function or series of functions, and for this reason they have "limits" of functioning-limits that are determined precisely by how they are constructed and the work they do. Many diseases abide by this simple rule.
The rectum is a kind of container in which feces accumulate to undergo the very last transformations before being eliminated; the anus constitutes the "gateway to the outside world" in this elimination mechanism, and therefore its activity is closely coordinated with that of the rectum. But this is not enough, because the "third actor" participating in the game, namely the feces, must be taken into account.
causes of internal hemorrhoidsIn the rectum, feces are accumulated, further dehydrated and then expelled outward, subject to the opening of the anal sphincters (which are two, one internal and one external). We have already mentioned that Hemorrhoids are part of this mechanism, because on the one hand they contribute to the sphincter mechanism, and on the other hand they accompany the feces outward.
That is, constipation and diarrhea (both, of course, for prolonged periods of time) are the main culprits in the changes that lead to hemorrhoidal disease. Consequently, a DIET POOR IN FIBERS, LACK OF INHABITATION OF LIQUIDS, SEDENTARY LIFE (things that all concur to cause constipation) can cause the onset of hemorrhoidal pathology. And in fact they are its main cause, far more important than diarrhea, since the latter is usually episodic, while constipation, far more often, is chronic.
A very important chapter is that of occurrence of hemorrhoidal pathology due to INCREASE IN ADDOMINAL PRESSURE. A classic example is PREGNANCY. Increased abdominal pressure causes increased pressure at the rectal level, and therefore also at the hemorrhoidal level, causing all those alterations (rupture of the fibers of the hemorrhoidal pads, elongation and deformation of the hemorrhoidal venous plexuses, etc. etc.) that we have already discussed. Pregnancy is among the causes of internal hemorrhoids as it causes a major increase in abdominal pressure, and even more so does PARTITION. It is very common to see pregnant or postpartum women with massive hemorrhoidal prolapses. These women MUST BE FOLLOWED BY A COLOPROCTOLOGIST, and especially THE SIMPLE USE OF LOCAL MEDICATIONS (POMATES, VASOPROTECTORS, ETC.) IS ALMOST ENTIRELY USELESS IF NOT MONITORED AND/OR ASSOCIATED WITH OTHER PROVISIONS that only the Coloproctologist is able to prescribe.
It is not uncommon for hemorrhoidal prolapses to APPARENTLY disappear after childbirth: but in fact the machine has been set in motion, and in the end, in women, pregnancy is probably the most important cause of hemorrhoidal pathology.
There is also, among the vcauses of internal hemorrhoids, a FAMILY PREDICTION to the development of the disease: as is the case with leg varices, those who have one or both parents who have suffered from hemorrhoids have a higher risk of developing the disease. This is for complex reasons of biochemical alterations in the tissues that make up the vessel walls of the hemorrhoid pads, a subject too specialized to be of interest: suffice it to know that it exists... so, going back to what was said at the beginning, if the machine is built badly, sooner or later it will stop working properly.

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Anal pain, anal pain, anal fissure, hemorrhoids, anal fistula
Doctor, I have hemorrhoids!!!

It's true!!! we all have them!!!

Pathology is often confused with normal anatomy. Hemorrhoids are, indeed, normal, even quite complex, anatomical structures that we all possess and that play a fundamental role in anorectal physiology, particularly in the physiology of defecation.

What are hemorrhoids?

Hemorrhoids, mucous prolapse, hemorrhoidal prolapse, mucohemorrhoidal prolapse, what are hemorrhoidsThe popular vulgate, often fueled even by us physicians, is that they are VENE. THEY ARE NOT. Then, what are hemorrhoids? They are actually Functional complexes consisting of arteries, capillaries, veins, connective and muscle fibers, and mucosa. Conventionally, we say that there are Three major hemorrhoid plexuses (which I, following the Spanish school, call front right, back right and side left; others, especially in Italy, enumerate them according to a "clockwise" criterion: "at one o'clock - at five o'clock - at nine o'clock"; to me this seems a tad farrago...) - although in reality, located among the main plexuses ACCESSORIES, smaller but equally important.

What are hemorrhoids for and how do they work?

Once we understand what hemorrhoids are, let's explain what they are for. Each hemorrhoid plexus is made up of a series of ARTERO-VENOSIC SHUNTS, i.e., veins and arteries that join together and form veritable VASCULAR CUSHIONS, the size of which can vary depending on the amount of blood they contain-which is, in turn, determined by arterial inflow and venous outflow into the "pads." These pads are covered by the mucous membrane of the last part of the rectum, and are, shall we say, "held in place" by a complex of connective and muscular fibers that ensure, moreover, their elasticity - and thus their ability to fill and empty with blood; in short, ultimately, VOLUME.

Thanks to their PLASTICITY, the hemorrhoid pads are able to perform their functions perfectly: which are to ACCOMPANY the feces toward their elimination, preventing the passage into the last part of the anorectal canal from being painful, and to PERFECT THE CLOSURE of the mouth of the anal canal, thus participating in the sphincter mechanisms of the anus. Alas, when the magnificent and complex fibrous scaffolding of the hemorrhoids becomes altered (and we will see the reasons for this another time) the problems begin... The connective and muscular fibers that constitute the support for the veins and arteries in the hemorrhoid pads can undergo alterations, which eventually cause them tostretch and/or rupture. The venous structures that make up the hemorrhoids then begin to "slide" downward, which causes them to become truly "deformed" (especially at the expense of the veins, which have, in contrast to the arteries, very little elasticity): the end result of this "degenerative" process (which, however, generally takes YEARS to develop) is HEMORROID PROLASSE.

The consequences, clinically speaking, are obvious: that valuable mechanism of accompanying stool and closing the anus that was regulated by hemorrhoids is broken; in addition, the elongated and deformed veins become more fragile, dilate, and can no longer empty. BLOODING (generally not painful) is the most frequent manifestation of hemorrhoidal pathology; the blood is "bright red," precisely because of its arterial origin, and may be noticed on toilet paper or, less frequently, in the toilet. Alteration of the sphincter mechanism may result in filtration of fecal matter, especially liquid, which causes IRRITATION and ANAL PRURITATION; finally, in the most important cases, there may be SOILING (i.e., minor fecal incontinence) or even STIPSI (the so-called "obstructed defecation syndrome"... a very complicated thing); not to mention the actual PROLAPSE, i.e., the outflow from the anus of a "mucous cylinder," consisting of the rectal mucosa, which sometimes no longer re-enters, which can ulcerate and bleed, and which for patients (who are often elderly, and therefore struggling with a thousand other conditions) is a huge problem.

Well, now we understand what hemorrhoids are, what they are for, and how they work. In a future article, we will see why they, from the normal structures that they are, turn into pathological entities. Stay tuned!

Pain after inguinal hernia surgery

It seems unbelievable, but even in the age of instant communication, where scientific knowledge can be transmitted and shared in real time, many Surgeons say that the problem of pain after inguinal hernia surgery does not exist, and that they do not remember having had, nor having treated, any patient with this type of problem.

However, the Literature reveals to us that in Centers where there is nodedicated abdominal wall surgery team, pain and burning after inguinal hernia surgery do exist, affecting, in extreme cases, as many as 60% of operated patients.

More realistically. Chronic inguinal pain after inguinal hernioplasty surgery may occur in about 20% of patients, predominantly outnumbering hernial recurrences, which instead occur in 3.3-10% of cases1.

But what exactly are we talking about?

Pain after inguinal hernia surgery, or chronic inguinal pain, is that pain that follows inguinal hernia surgery; it is due to nerve injury and must be present at least 3 months after surgery and persistent for at least 6 months. It can be caused by, among other things, inflammatory reactions of the periosteum of the pubis (the periosteum is a thin, tough membrane that lines the bones; pain in this case may be triggered, for example, by the so-called "stitch on the pubis" that so pleases surgeons not especially dedicated to hernial surgery, and which has been absolutely proscribed by wall surgeons for years now), by nerve injuries occurring during surgery fromentrapment of nerve branches in the inguinal region at mesh fixation sites (for this we prefer the Trabucco technique, which does not require stitches on the mesh), from "perforations" of nerve branches due to theuse of tacks (tacks are clips, usually resorbable, that can be used laparoscopically to fix the mesh; although wall surgeons well know that, for example, in laparoscopic inguinal hernia surgery, it is not necessary to fix the mesh...) or from theinclusion of nerve branches in "meshomas " ("mesh" = mesh), granulomatous lesions caused by the inflammatory reaction of the patient's tissues toward the implanted mesh (normally in the case of heavy or not well stretched mesh; that's why wall surgeons, well aware of this problem, try whenever they can to use light mesh).

Pain after inguinal hernia surgery may be associated with paresthesias (i.e., "different" skin sensitivity than normal), hypoesthesias (i.e., reductions in skin sensitivity), and hyperesthesias (i.e., a conspicuous increase in skin sensitivity), and radiate toward the scrotum, labia majora, and Scarpa's triangle (the root of the thigh). Symptoms may be triggered, or exacerbated, by certain positions, such ashyperextension of the thigh, or activities, such as walking; and sometimes may decrease with thigh flexion or when lying down.

Following inguinal hernia surgery, pain months after surgery can thus be defined as chronic inguinal pain; and chronic inguinal pain can cause changes in the central nervous system that contribute to its persistence and aggravation. The consequence is the appearance of two conditions that are typical of chronic groin pain:hyperalgesia (exaggerated response to painful stimuli) andalodynia (pain triggered by stimuli that would not normally elicit any painful response). Therefore, it is important to treat postoperative inguinal hernia pain before it becomes chronic, since its chronicity implies plastic changes in the brain centers of pain: early treatment, on the other hand, can prevent such changes from occurring.

Pain after inguinal hernia surgery: how to treat it?

The initial treatment of the pain after inguinal hernia surgery is medical; only later is surgery used. The first, fundamental step in the Treatment of pain and burning after inguinal hernia surgery is to draw a Skin map of the pain itself, as in the figure opposite. With the patient lying down, you Inguinal hernia pain after monthsprovoke tactile stimuli in the groin region affected by the pain: depending on the type of sensation reported by the patient (pain, hypoesthesia, normoesthesia, hyperesthesia...) a circle or a cross of different color is drawn at the various stimulated points. Eventually you will get a map like the one opposite, which will allow the surgeon to know which injured nerve is causing the pain. The Surgeon will then prescribe topical or oral medication, according to a well-established and validated schedule: if, at the end of the treatment period, there is no satisfactory improvement, the Surgeon will propose surgery.

The surgery for the treatment of chronic inguinal pain consists of triple neurectomy, that is, theremoval of the nerve branches that cause the onset of the pain itself. This surgery can be performed either by the traditional route, reoperating the inguinal region (with the risk, however, given the inflammatory and scarring processes following hernia repair surgery, that the nerve branches will be very difficult to identify), or by the laparoscopic route, with an extremely refined technique. Our group prefers this second route, although sometimes it may be necessary to use a mixed technique, either open or laparoscopic, to satisfactorily complete the operation.

In conclusion, when a Surgeon treats a person with chronic groin pain he must, first of all, become a Physician again; and not just any Physician, but the best Physician possible for his "patient. In the end, only in the end, he must put on the shoes of the Surgeon again; and not just any Surgeon, but the best Specialist Surgeon possible.

Do you suffer from chronic groin pain resulting from inguinal hernia surgery? Contact us!

1. K.-J. Lundström H. Holmberg A. Montgomery P. Nordin. Patient-reported rates of chronic pain and recurrence after groin hernia repair. Br J Surg. 2018;105(1):106-112


Do you want to contact us? Use the form below!

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Dr. Salvatore uccomarino
Medical Surgeon Specialist in General Surgery
Laparoscopic inguinal hernia surgery REPA, the minimally invasive endoscopic surgery for diastasis of the rectus
51 Amerigo Vespucci Street
Phone 0110438161

Botulinum toxin A in laparocele surgery

All of the Surgeons who deal with. abdominal wall have a primary goal to achieve in their interventions: that of achieving the so-called "tension-free" repair, that is, a repair in which the means used to repair the wall defect - the sutures, the prosthesis...-are not under tension.
There is no clear agreement in the international surgical community on what "tension" is. However, it appears that at least two factors play an important role in determining tension: theIncreased pressure within the abdomen and the so-called "distractive forces" of the abdominal wall, that is, those that tend to increase the diameter of the wall defect, be it a hernia, a laparocele or a diastasis of the rectus. To balance the effect of these "tensional" forces, the Surgeon has several weapons at his disposal, which he uses according to his experience and skills: from the more classic ones, such as the separation techniques ofanal fissure, anal fissure, anal pain, botulinum toxin a, laparocele, rectus diastasis, abdominal wall surgery, abdominal wall components or the use of large prosthesis, to more modern ones, such as the preoperative use of adjuvant techniques such as the botulinum toxin A and the preoperative progressive pneumoperitoneum. On the Surgeon's side there are then some "biological" factors, such as the ability of the organism to "integrate" (i.e., to make the prostheses used become part of itself): the latter ability, however, also depends on the material of which the prosthesis is made, and the position in which it is placed. Today we know, for example, that it should be avoided as much as possible to place a mesh inside the peritoneum, in contact with the abdominal viscera, because of the damage it may cause to the latter; and that in any case, even when placing an intraperitoneal prosthesis, the wall defect should always be sutured first. This last indication - the so-called IPOM PLUS technique - Unfortunately, it is followed by very few surgeons in Italy today, as the abdominal wall surgery is not still considered an autonomous specialty, and there are very few Professionals who have specific training in this regard.

Then there are "patient-side" factors that sensitively affect repair tension: the most important isobesity-and in fact no Wall Surgeon would operate (unless in an emergency situation) on an obese patient without first getting him or her to lose weight, even resorting to bariatric surgery if necessary.
Extremely important and interesting from the point of view of surgical technique are the "distractive" forces. When a defect in the abdominal wall forms, especially if it is apost-surgical hernia (also known as an incisional hernia or laparocele) or a diastasis of the rectus, the three lateral muscles of the abdomen (external oblique, internal oblique, and transverse) lose one of their insertions, the medial one, on the fascia of the rectus muscles of the abdomen; over time the muscles go into fibrosis, shorten, thicken, and lose, at least in part, their elastic capabilities. When it comes to surgery, such profound structural changes in the muscles are one of the main causes of repair tension, especially if the defect is large. This explains why if abdominal wall defects, and especially anincisional herniaor laparocele, or even a large diastasis of the rectus, are repaired with a simple suture and without using prostheses, recurrences, 10 years after surgery, are up to 50 percent of cases.
Laparocele is always consequent to a laparotomy, i.e., surgery involving incision of the abdominal wall (e.g., after surgery for removal of the gallbladder, appendix, open bowel cancer, removal of the uterus, etc.) and is common in patients undergoing surgery for cancer. We know that if, at the time of laparotomy closure, we use a "prophylactic" mesh (i.e., a mesh implanted for the purpose of reducing the likelihood of laparocele formation), the incidence of laparocele itself, at 10 years, plummets to 5-10%. The "prophylactic" mesh is normally much smaller than those used in laparocele repair: this is because at the time of laparotomy closure, the muscles are much more elastic than those of a patient with a laparocele, and can be easily brought closer together.
From this simple but important observation, an equally simple idea was born: if the muscles of patients with a large abdominal wall defect - a laparocele, for example, as mentioned; but also a large diastasis of the rectus with a diameter of more than 8 cm - could be restored to their original length and elasticity, the tension of the sutures at the time of laparocele repair would be greatly reduced, and consequently the risk of recurrence would be reduced.
This idea was first applied to laparocele surgery by an ingenious Mexican surgeon, Dr. Tomás Ibarra Hurtado, in 2007. Dr. Ibarra Hurtado thought that the

Botulinum toxin A, laparocele, rectus diastasis, abdominal wall
Dr. Tomás Ibarra Hurtado

Dr. Ibarra Hurtado teaches us his technique with botulinum toxin A

botulinum toxin A, a drug widely used both in neurology (e.g., for the treatment of facial muscle spasms), in plastic surgery (for the treatment of facial wrinkles), and in proctology (for the treatment of anal fissures), injected into the muscles of the abdominal wall prior to laparocele surgery, could cause those muscles to relax: at this point, the pressure exerted on those muscles by the viscera contained within the abdomen would cause them to lengthen. This hypothesis was confirmed by CT studies carried out at 2 to 4 weeks of toxin administration: in patients undergoing such treatment, all of whom had large laparoceles, the lateral muscles of the abdomen were indeed significantly lengthened and thinned. This makes it much easier to bring the muscles closer together and thus repair the defect without tension.
Dr. Ibarra Hurtado's technique is now widely used throughout the world, and used by leading surgeons specializing in abdominal wall repair. In Italy, however, our group-I learned the technique directly from Dr. Ibarra, as part of a splendid seminar he held in 2018 in Madrid during the congress of the Sociedad Hispano-Americana de Hernia-is the only one to use botulinum toxin A in reconstructions of large wall defects.
The effect of botulinum toxin A persists for about 3 months; in this time frame, tissue repair processes and prosthesis integration progress to such an extent that, once the effect of the toxin has ceased, the soundness of the repair is no longer at risk.
The use of botulinum toxin A in the surgery of large wall defects has confirmed that the main risk factor for recurrences of laparoceles and other large abdominal wall defects (such as large diastases of the rectus, with diameters greater than 8 cm) is precisely suture tension. Its use, together with other preoperative strategies of preparation and optimization of the surgery (e.g., weight loss, smoking cessation, diabetes control, etc.) allows to significantly reduce recurrences and postoperative pain and to use smaller mesh sizes.
In our country, the National Health System does not recognize the use of botulinum toxin A for abdominal wall surgery; therefore, as mentioned above, its use is virtually unknown.


Dr. Salvatore Cuccomarino
Cuccomarino, MD
Dr, Cuccomarino coordinates a multidisciplinary medical team dedicated to the treatment of abdominal wall defects. He was the first in Europe to perform REPA, the minimally invasive endoscopic surgery of diastasis of the rectus.
61 Amerigo Vespucci Street
Phone +39 011 0438161


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anal pain, anal fissure, anal fissure, botulinum toxin
Anal pain? It's probably a fissure

Anal pain, anal fissure, anal fissure, botulinum toxinThe anal pain is one of the causes more frequent prompting patients to undergo proctological examination; and the anal fissure Is the most common cause of anal pain.

La anal fissure is a small tear in the skin lining the anal canal. It is a fairly common condition, however, often confused with other conditions that can cause anal pain and bleeding, first and foremost hemorrhoids (although the latter, at least in their early stages, hardly cause pain).

The typical symptoms of anal fissure include anal pain during and/or after defecation and bleeding. Typically, the pain is very intense, resistant to common analgesic therapies, begins with defecation and lasts for hours. It is not uncommon for patients to try to avoid going to the bowels because of the severity of the pain, in this way fueling a vicious cycle that causes worsening symptoms (intense pain -> patient refrains from going to the bowels -> constipation worsens, stools become dehydrated, and fecalomas form -> at the next defecation the pain increases in intensity).

In most cases, the fissure is characterized by increased pressure on the internal anal sphincter. Again, a vicious cycle takes place: anal pain causes further contraction of the sphincter, which in turn causes a decrease in blood flow to the area of the fissure, which prevents it from healing.

La anal fissure normally has a traumatic origin, being caused by anything that cananal pain, anal fissure, anal fissure, botulinum toxin Tear or irritate the skin lining the anal canal. The most typical cause is constipation. They can be acute, chronic, and recurrent; the latter are sometimes associated with a small external nodule called a sentinel polyp.

Diagnosis is made on the basis of clinical history and inspection; normally the fissure is located on the posterior midline of the anal canal, less frequently on the anterior and rarely elsewhere. A key instrumental diagnostic aid is anal manometry, which can distinguish cases with sphincter hypertone from those, much less frequently, in which anal sphincter pressure is normal. 

The treatment of anal fissure

In most cases, simply treating constipation can achieve healing of the fissure. Treatment of acute fissures in almost 90 percent of cases consists of general hygienic measures and local dressings: a diet rich in fruits and vegetables, the intake of high-fiber pharmacological supplements, special stool lubricants such as vaseline oil, and fluids, together with adequate physical activity, help to cure constipation, promote bowel motility, and promote healing of the fissure. Baths in warm water, lasting 10-20 minutes and repeated several times a day after defecation and before bedtime at night, promote relaxation of the anal muscles and contribute to wound healing. Appropriate local therapy, based on nitroglycerin and local anesthetics, causes detente of the anal sphincter and soothes anal pain; this improves the vascularization of the fissure and promotes its healing. Anal dilators also give good results; however, they are not always tolerated by patients.

Botulinum toxin in the treatment of anal fissure

anal fissure, anal fissure, anal pain, botulinum toxinIn recent years, the use of the botulinum toxin injected at the level of the sphincter area led to excellent results.

Botulinum to xin is a proteinaceous neurotoxin produced by a bacterium, Clostridium botulinum. There are seven types of botulinum toxin, labeled with letters A through G. Type A botulinum toxin has been used for decades in cynicism for the treatment of spasms and dystonias, including cervical dystonia or spastic torticollis, blepharospasm, severe primary axillary hyperhidrosis, and strabismus. In aesthetic medicine, botulinum toxin is widely used for the treatment of facial and neck wrinkles.

The use of botulinum toxin in the treatment of anal fissure was first reported in 1993 by W. Jost et al. Since then, studies on the efficacy, both from the point of view of overall cost, outcome, and post-treatment complications compared to local medical therapy with substances such as nitroglycerin that I mentioned earlier and to surgery have multiplied, and have led some Authors to state that the introduction of botulinum toxin in the treatment of anal fissure is comparable to the introduction of laparoscopy in surgery. The main data can be summarized as follows:

  • the efficacy of treatment is dose-dependent and site-dependent (to one side, or both sides, of the fissure, or in the anterior midline, taking into account that the majority of fissures occur in the posterior midline), although, to date, there is no unanimous consensus on the site and dose of injection;
  • sphincterotomy remains the gold standard for the long-term treatment of anal fissure (75.4 percent healing of fissure with botulinum toxin at 12 months versus 94 percent with sphincterotomy); however, sphincterotomy is burdened with a significantly much higher rate of serious complications than botulinum toxin treatment; in a recent study, the use of botulinum toxin in the treatment of anal fissure showed superior efficacy in terms of safety compared with internal anal sphincterotomy;
  • treatment with botulinum toxin is well tolerated, is performed on an outpatient basis, is very effective, and has a very low incidence of complications; it is probably more indicated in elderly patients at greater risk of developing anal incontinence if they undergo sphincterotomy, while surgery remains the best option in young adults with good sphincter tone.

Despite this, and despite the amount of data over time that have demonstrated the efficacy and safety of botulinum toxin in the treatment of anal fissure, this indication is to date off-label, and the treatment is not available in National Health Service hospitals.
The surgical treatment of anal fissure, which is very effective and burdened by a low recurrence rate, consists of internal lateral sphincterotomy, that is, the incision of a small part of the internal sphincter muscle of the anus. It is generally a very welcome procedure for the patient, who sees his anal pain disappear overnight. Most patients go so far as to claim that the same, normal postoperative pain is absolutely negligible compared to the suffering inflicted up to that point by the fissure. Surgery may be followed, in a very small percentage of cases, by modest incontinence to gas and, much more rarely, to feces, which normally disappear as the surgical wound heals. It is quite exceptional that, if the surgery is performed correctly, any incontinence to feces will not regress postoperatively and become chronic.

Recurrent anal fissure

Unfortunately, fissures recur frequently, and usually constipation is always the main cause. Therefore, once the fissure has healed and the pain has disappeared, the effort must be directed toward keeping the stool soft and well lubricated, taking in adequate amounts of fruits, vegetables, and fluids through diet, and, if necessary, continuing to use dietary fiber supplements and Vaseline oil.

What if drug therapy doesn't work?

In these cases, a coloproctologic reevaluation is mandatory. The causes of anal pain are numerous, so the differential diagnostic process is crucial. Among them, in addition to anal fissure, it is worth mentioning:

  • anorectal fistula
  • Coccygodynia (coccyx pain with no apparent cause)
  • thrombosed external hemorrhoids
  • anus elevator syndrome
  • perianal abscess
  • perianal hematoma
  • solitary rectal ulcer syndrome
  • ulcerative colitis
  • anal neoplasms
  • anal sex

Once the absence of these conditions is assured and the presence of the fissure and, on manometry, increased anal sphincter pressure is confirmed, patients with fissures that do not go to healing can be considered for indication for surgical treatment.

waiting times in the NHS
Waiting times in the NHS: why wait?

waiting times in the NHSI waiting times in the NHS, in recent years, unfortunately, have expanded enormously. The continuous spending cuts, Interest focused on only a few pathologies - undoubtedly important, but not the only ones, and perhaps nealso the most frequent - the failure, for economic reasons, to renew operating room equipment and principals, and the limited opportunities for physicians to keep up to date, often crushed by very heavy shifts due to the blocking of turnover - again for economic reasons - of health personnel in public hospitals, mean that many patients have to wait many months if not years to undergo surgery - for example, for diseases that are undoubtedly benign but often seriously interfere with the daily life of the sufferer.
I am talking especially about the proctological pathologies, as hemorrhoids, anal fissures, anal fistulas, and of the abdominal wall pathologies - inguinal hernias, umbilicals, epigastric, diastasis of the rectus abdominis muscles. Conditions that often afflict young, busy patients, interfering with their well-being, their daily commitments, and their serenity.
Today many people, in order to obviate the intolerable increase in the waiting times in the NHS of our country, resort to the integrative health care, taking out insurance that allows them to deal with their health problems without worry and in the right timeframe. For those who may not yet have access to these forms of insurance, which are actually The future for health protection in our country, our group has agreed, with primary clinics in Turin, of the surgical benefit packages, which allow the intervention to be approached for hemorrhoids, anal fissure, perianal fistula, inguinal hernia and umbilical at a low cost and by installment, if desired.
NHS waiting times, hemorpex system, HPS, hemorrhoids, dearterization, hemorrhoid dearterization, THDAll using the most modern and minimally invasive techniques: for example, for the treatment of hemorrhoids up to grade III, the HPS (HemorPex System) technique, which makes it possible to greatly contain postoperative pain and to Discharge the patient on the same day as the surgery, with a quick return to his life and normal activities
To get more information or request a quote, email us at. info@cuccomarinomd.com o contact us through our social od the contact form below.


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Cuccomarino, MD
Dr. Salvatore Cuccomarino's surgical team, for the future of Surgery. Turin.
Turin, TO
Phone 0110438161

agreements with health insurance companies
Conventions with health insurance companies

The portfolio of the agreements with health insurance companies Of our Team. agreements with health insurance companiesThanks to recent agreements with the prestigious Fornaca Nursing Home of Sessant of Turin, joining those already active for some time with the Pinna Pintor Nursing Home (Monza Polyclinic Group) we are now able to offer our patients a very wide range of agreements with health insurance companies, which is complemented by the possibility, at the Fornaca Nursing Home in Sessant, to installment the costs of surgical procedures according to formulas convenient for the patient.

Here is the list of agreements with health insurance companies (those exclusive to Pinna Pintor Nursing Home are indicated with *):

  • AGA*
  • Allianz Worldwide Partners
  • AON Hewitt
  • Assirete
  • Assist Card
  • Bank of Alba
  • Blue Assistance
  • C.A.M.P.A.
  • Casagit Services
  • Casagit
  • Caspie
  • Celta Assistance
  • Cigna
  • Europ Assistance
  • FAB
  • FAIT
  • FASI / FASI Open
  • Ferrero
  • Direct Wire*
  • Health Fund
  • General
  • Credito Valtellinese Banking Group
  • ITC
  • Together Health
  • Inter Partner Assistance (IPA)
  • Med 24 / Med 24 Assistocard
  • Medic4all*
  • My Assistance
  • My Network
  • Nobis Insurance Company
  • Previmedical
  • Pro.Ge.Sal for All
  • Sara Insurance*
  • Provincial Secretariat of the Trade Union Organization UGL - PS Turin
  • Unisalute
  • WIT Health Division


Dr. Salvatore Cuccomarino
Cuccomarino, MD
Medical Surgeon Specialist in General Surgery
Galileo Ferrararis course 3
Phone 0110438161

Laparoscopic recurrent inguinal hernia
Recurrent inguinal hernia? better laparoscopy

Recurrent inguinal hernia: what is it?

L'inguinal hernia belongs to the large family of hernias of the abdominal wall and represents one of the most frequent diseases of surgical interest worldwide: it is estimated that hernias in general affect 5 to 7 percent of the population, and of these about 75 percent are inguinal hernias. In other words, about 2,736,000 people in Italy are affected by inguinal hernias. The majority of these patients end up undergoing surgery, which, in the first instance, is a relatively uncomplicated procedure that is performed under local anesthesia and requires only a few hours of hospitalization. However, in not a small percentage of cases, the repair, for a variety of reasons (ranging from errors in technique to the patient's failure to follow the rules imposed by the surgeon in the postoperative), fails; the hernia reforms: we speak, in this case, of recurrent inguinal hernia.

Recurrence: a frequent problem in inguinal hernias

Modern surgical techniques and the use of prostheses have substantially reduced the rate of recurrence after inguinal hernia surgery; however, a recent study, conducted on more than 46. 000 patients in Denmark, showed that the incidence of inguinal hernia recurrence continues to affect about 4 percent of patients; less than the double-digit percentages observed before the advent of mesh: but, taking into account the numbers reported earlier, theoretically in Italy alone,inguinal herniarecurrence affects more than 100,000 patients-a not a small city!

The problem then facing the Surgeon is: what is the correct treatment of recurrent inguinal hernia?

What is the correct treatment of recurrent inguinal hernia?

Most Surgeons treat therelapsed ing uinal hernia exactly as they had treated the primary inguinal hernia: that is, they operate on it anteriorly, redoing a surgical incision on the previous one, and trying to put a "patch" on it as best they can-very often "inventing" on the spot some variation of the most commonly used surgical techniques (which, in the act, also seems like a good solution). This, unfortunately, is conceptually wrong, as well as going against the indications of the main guidelines available today.

Operating a recurrent hernia with the traditional incision when the primary hernia has already been operated on anteriorly means re-injuring tissue over which the surgeon had already passed during the previous operation, in an area where the anatomy has been profoundly altered by the surgery undergone by the patient anyway, and where there are very intense fibrotic phenomena due to the presence of the mesh: the risk of vascular and nerve injury and postoperative pain increases, and by a great deal; the wall of the inguinal region is further weakened, and the risk of recurrence increases. The patient risks being entangled in an endless and painful odyssey.

Hernia recurrence: better laparoscopy

Le guidelines, in this case drawn up by the European Hernia Society, speak clearly: Recurrent inguinal hernia, guidelines, European Hernia Society

"If previously anterior: consider open preperitoneal mesh or endoscopic approach (if espertise is present)" - i.e., if the patient has previously been operated on anteriorly, open repair with mesh in the preperitoneal position (e.g., Stoppa's or Wantz's techniques) or the endoscopic technique are indicated, provided expertise is present, i.e., there is a Surgeon experienced in this procedure.

In fact, in Italy - for a thousand reasons, which it is not the case to analyze here - there are few Surgeons able to try their hand at inguinal hernia repair laparoscopically, especially if it is arecurrent inguinal hernia (and perhaps even fewer who are able to perform an operation with Stoppa or Wantz technique). These are difficult cases, with altered anatomy in any case (even if, "going from the inside," i.e., from the inner surface of the inguinal region, one is working in seemingly "virgin" territory), which can only be addressed by experienced surgeons. But the advantages are clear: one has the possibility of repairing the herniated defect with a significantly larger mesh than is used in traditional hernia surgery, placed in a "healthy" area than where the surgeon had previously worked; and not infrequently, one may find that one is actually not dealing with arecurring inguinal hernia, but with a new hernia, perhaps unnoticed during the previous surgery, or perhaps formed later; and that, lo and behold, there is also a hernia on the other side, in the other inguinal region, which neither the patient nor the surgeon had noticed, and which can be repaired during the same surgery, before it begins to bother. Not to mention that postoperative pain is significantly less than with traditional surgery, and the patient can return to his or her activities much more quickly.

The video of the surgical technique

And here, finally, is a video of a recent surgery I did for recurrent inguinal hernia, performed laparoscopically (T.A.P.P. technique, Trans Abdominal Pre Peritoneal). This was a utrasectomy patient in his fourth recurrent hernia (!!! That is, three other surgeons had already operated on him by going through the anterior route, evidently without great results). Not an easy surgery, as expected, but successfully concluded to the patient's satisfaction. The mesh, as prescribed by the guidelines, is placed in the preperitoneal space, but without the large incisions required for Stoppa or Wantz techniques (in fact, the patient will be left with three small scars, two 10 mm and one 5 mm...).

The patient was discharged the day after surgery, and had no discomfort or complications in the postoperative period. These results are obtained in the vast majority of cases of patients operated on laparoscopically. But - I repeat - laparoscopic inguinal hernioplasty , especially in cases of recurrent inguinal hernia, is not for everyone, and must be performed by an experienced surgeon.

Enjoy your viewing!

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Dr. Salvatore Cuccomarino
Cuccomarino, MD
Medical Surgeon Specialist in General Surgery
Corso Galileo Ferraris 3
Phone 0110438161