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Strangulation is a common presentation of acute abdominal wall hernias that usually requires emergency surgery. The aim of this report is to propose a "reverse strategy" combining an open mesh-based anterior approach followed by a "conversion" to laparoscopy for the treatment of strangulated hernias.A 68-year-old male patient came to the emergency room of our university hospital with a non-reducible left groin hernia. The CT scan demonstrated a left groin strangulated hernia with doubtful viability of the involved bowel loop. We decided to perform a transversal inguinotomy followed by a laparoscopic approach through the inguinal ring.The patient was discharged after four days in perfect general condition, with normal bowel function and no postoperative pain.We propose this unconventional conversion from open to laparoscopic surgery as a new indication for the laparoscopic approach in emergency hernia surgery. We hope it can be used as a gold option for the surgical treatment of strangulated hernia in selected cases.

Most of the indoor coverage issues arise from network deployments that are usually planned for outdoor scenarios. Moreover, the ever-growing number of devices with different Radio Access Technologies (RATs), expected for new 5G scenarios and to maintain compatibility with older cellular standards (mostly 3G/4G), worsen this situation thus calling for novel bandwidth-efficient, low-latency and cost-effective solutions for indoor coverage. To solve this problem, Centralized Radio Access Network (C-RAN) architectures have been proposed to provide dense and controlled coverage inside buildings. However, all-digital C-RAN solutions are complex and expensive when indoor layout constraints and device costs are considered. We discuss here an analog C-RAN architecture, referred to as Analog MIMO Radio-over-Copper (A-MIMO-RoC), that aims at distributing RF signals indoors over distances in the order of 50 m. The all-analog passive-only design presented here proves the feasibility of analog relaying of MIMO radio signals over LAN cables at frequency bandwidth values up to 400 MHz for multi-RAT applications. After asserting the feasibility of the A-MIMO-RoC platform, we present some experimental results obtained with the proposed architecture. These preliminary results show that the A-MIMO-RoC system is a valid solution towards the design of dedicated 4G/5G indoor wireless systems for the billions of buildings which nowadays still suffer from severe indoor coverage issues., Part of this work has been accepted in IEEE TCAS II

Additional radiofrequency ablation (RFA) of liver-limited colorectal liver metastases (CRLM) improves overall (OS) and recurrence-free survival (RFS) over systemic therapy alone. We aimed to assess the potential and predictive factors of long-term survival and cure to optimize patient selection for RFA application.Retrospective review of a prospectively maintained single-center database of consecutive patients undergoing RFA for liver-limited CRLM after systemic therapy between 2002 and 2020. Clinicopathologic characteristics and KRAS/BRAF-genotype data (tested routinely since 2010) were correlated to RFS and OS. Cure was defined as ≥10-years RFS (long-term survival as ≥5-years OS) following RFA.For the entire cohort of 158 patients (median follow-up 13.6 years), co-occurrence of three factors, RECIST-defined response, number of ≤3 CRLM, and ≤3 cm maximum size determined a survival plateau that distinguished cured from non-cured patients (10-years RFS: 15.5% vs 0%, p 0.0001). Among 59 patients (37.3%) being tested, 4(6.8%) were BRAF-mt, 15(25.4%) KRAS-mt, and 40(67.8%) KRAS/BRAF-wt. OS (median follow-up 8.3 years) was estimated to be higher with KRAS/BRAF-wt compared to a mutant KRAS or BRAF status (5-years OS: 22.8% vs 3.4%, p = 0.0018).This study indicates about 15% chance of cure following RFA of low-volume liver-limited CRLM after downsizing by systemic therapy and a negative effect of KRAS or BRAF mutation on long-term survival after CRLM ablation. These findings may improve clinical decision-making in patients potentially candidate to RFA of CRLM and encourage further investigations on molecular factors determining an oligometastatic state of CRLM curable with focal ablative therapy.

Patient: Female, 83-year-old Final Diagnosis: Sclerosing mesenteritis Symptoms: Abdominal pain • intestinal obstruction • vomiting Medication: — Clinical Procedure: — Specialty: Surgery Objective: Rare disease Background: The term “sclerosing mesenteritis” includes a spectrum of rare idiopathic diseases involving the small and/or large bowel. It appears as a diffuse, localized, or multinodular thickening of the mesentery, with a variable degree of chronic non-specific inflammation, fat necrosis, and fibrosis. Case Report: Here, we report a case of 83-year-old woman with symptoms of intestinal occlusion, vomiting, and abdominal pain. Radiographic examinations showed air fluid levels in right and left quadrants and in the mesogastric site, while computed tomography (CT) documented a strangulated inguinal hernia with ileal obstruction. Based on clinical examination and radiologic findings, the patient underwent surgery for inguinal hernia reduction. The examination of viscera revealed 2 tracts of ileum with ischemic signs and covered by fibrin; thus, the 2 intestinal loops were resected. Histological examination revealed chronic non-specific inflammation of the whole intestinal wall, including the subserosa in the resected tract of proximal ileum, while the distal ileal loop (not herniated tract) showed a subserosal fibrous nodule of 2 cm in greatest diameter, composed of a proliferation of spindle cells haphazardly arranged in a collagenized stroma. The diagnosis of sclerosing mesenteritis was rendered. Conclusions: The present case shows the possibility of an incidental diagnosis during another intervention such as hernia surgery. Pathologists should be aware of this disease to avoid confusion with aggressive tumors such as intra-abdominal desmoid-type fibromatosis and gastrointestinal stromal tumor.

Until the 1980's, Klatskin tumors were considered ‘desperate cases’ and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.

Since there is still no univocal codified treatment for mesh infection or fistulization following abdominal wall repair, the aim of this study is to propose a diagnostic and therapeutic flowchart based on personal experience and literature review. We retrospectively evaluated 12 patients who developed mesh infection or enterocutaneous fistulas after mesh implantation for abdominal wall hernias. Patients had had different types of mesh implanted: 6 polypropylene meshes, 3 expanded polytetrafluoroethylene (ePTFE) meshes, 2 dual mesh, and 1 polyester mesh. Based on our experience and literature review, we extrapolated a diagnostic and therapeutic flowchart. The clinical course and results of treatment were heterogeneous in this group of patients. Four patients (33%) underwent fistulectomy with excision of the fistulous canal in association with removal of the infected mesh. One patient (9%) underwent fistulectomy with partial removal of the polypropylene mesh and resection of the affected tract of the ileum. Five patients (42%) underwent excision of the infected mesh. Conservative treatment was resolutive in two cases (16%). Of the 10 cases with a surgical procedure, in two cases a conservative approach with total parenteral nutrition (TPN) was initially adopted; this approach may have reduced the invasiveness of the surgical procedure. Three patients (25%) experienced a chronic fistula, nine patients (75%) healed and showed no recurrence after a mean follow-up of 18 months. The approach to mesh fistulization should be tailored to every single patient. In the majority of cases, a multistep approach seems to be necessary.

Background The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. Methods An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. Results A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Buchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment. Conclusion Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

Background: ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series. Methods: After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome. Results: In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy. Conclusion: In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.

Analog Multiple-Input Multiple-Output Radio-over-Copper (A-MIMO-RoC) is an effective all-analog FrontHaul (FH) architecture that exploits any pre-existing Local Area Network (LAN) cabling infrastructure of buildings to distribute Radio-Frequency (RF) signals indoors. A-MIMO-RoC, by leveraging a fully analog implementation, completely avoids any dedicated digital interface by using a transparent end-to-end system, with consequent latency, bandwidth and cost benefits. Usually, LAN cables are exploited mainly in the low-frequency spectrum portion, mostly due to the moderate cable attenuation and crosstalk among twisted-pairs. Unlike current systems based on LAN cables, the key feature of the proposed platform is to exploit more efficiently the huge bandwidth capability offered by LAN cables, that contain 4 twisted-pairs reaching up to 500 MHz bandwidth/pair when the length is below 100 m. Several works proposed numerical simulations that assert the feasibility of employing LAN cables for indoor FH applications up to several hundreds of MHz, but an A-MIMO-RoC experimental evaluation is still missing. Here, we present some preliminary results obtained with an A-MIMO-RoC prototype made by low-cost all-analog/all-passive devices along the signal path. This setup demonstrates experimentally the feasibility of the proposed analog relaying of MIMO RF signals over LAN cables up to 400 MHz, thus enabling an efficient exploitation of the LAN cables transport capabilities for 5G indoor applications., Part of this work has been accepted as a conference publication to ISWCS 2019

Superficial venous aneurysms are a very uncommon disease probably associated with thrombosis and recurrent pulmonary thromboembolisms. Surgical treatment is safe and is performed in symptomatic cases. Surgical repair of superficial venous aneurysms is a recommended treatment, and no postoperative complications usually occur. The aim of this study is to report our experience treating superficial venous aneurysms, because they can cause devastating consequences. Obviously, they should be surgically treated if they are symptomatic, but there exists the possibility of complications such as thromboembolic events; however, they are unpredictable. Thus, the only solution to remove the potential risk of developing pulmonary or other embolic events is prophylactic surgery and anticoagulant therapy, also in low-risk patients.

Background: Most patients undergoing radiofrequency ablation (RFA) of colorectal liver metastasases (CLM) develop disease recurrence, but little is known about the effect of recurrence patterns and/or systemic therapy on outcome. In this study, we examined the recurrence patterns and survival after systemic therapy plus RFA in patients with unresectable CLM without extrahepatic disease. The aims were to analyze the effect of recurrence patterns on survival and to assess the relative benefit contributed by systemic therapy and local ablation to disease control and patient outcome. Methods: From January 2002 to December 2012, 113 patients underwent RFA of liver-limited CLM after systemic therapy. Univariate and multivariate analyses for associations between clinical and/or treatment-related variables, recurrence-free survival (RFS), recurrence patterns, and overall survival (OS) were carried out. Results: Of 113 patients, 105 (92.8%) had disease recurrence (median RFS: 6.1 months). Lower post-recurrence OS was observed after early (≤6 months) than after late recurrence (8.5 versus 24.0 months, p < 0.001). Recurrence sites were RFA-sites only (4.8%), liver-only (57.1%), lung-only (10.5%), or multiple (27.6%); the corresponding post-recurrence OS was 21, 19, 39, and 7 months (p < 0.001), respectively. Response to pre-RFA systemic therapy was the strongest predictor for OS (hazard ratio [HR] 5.28), RFS (HR 3.30), early (odds ratio [OR] 6.34) and multiple-site recurrence (OR 3.83) (p < 0.01), respectively; only responders achieved 5-year OS and RFS (29% and 12% versus 0% and 0% for non-responders, p < 0.001, respectively). Conclusions: Survival after RFA for liver-limited CLM is strongly linked to the timing and pattern of non-local disease recurrence. Local ablation efficacy is necessary but not sufficient to obtain long-term disease control. Effective pre-RFA systemic therapy does favourably affect the incidence, timing and patterns of recurrence and long-term survival and appears essential for the tailoring of RFA application to maximize patient benefit.

Next generation (5G and beyond) communication networks are expected to incorporate the pre-existing LTE and WiFi connectivity of all the interconnected devices with multiple available interfaces, guaranteeing high-rate/low-latency communications. In this context, Dual-RoC is the integration of Multi Radio Access Technology (RAT) into a copper-based Centralized Radio Access Network (C-RAN) architecture. Dual-RoC is proposed and validated here as it is an attractive solution, especially for indoor deployments. The objective of Dual-RoC is thus to experimentally observe the interplay between an all-analog C-RAN architecture based on LAN cables and Multi-RAT. In particular, in this paper we demonstrate experimentally and for the first time the capability of LAN cables to simultaneously relay both LTE and WiFi signals to commercial devices using all-analog relaying over copper cables.

First International Consensus Meeting, Hamburg, Germany, 27–28 February 2015 More than 160 participants took part in the conference for 2 days. A total of 58 world renown experts on ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) were invited from all over the world. The faculty was divided into many different subgroups that were in contact during the 2–3 months before the conference analyzing all the most important aspects of this technique and summarizing it in a common structured work to be presented during the congress, giving final recommendations in the form of bulleted point statements. The aim was to gain a solid basis of preliminary agreement on many controversial aspects of ALPPS. A poster area was also organized with 35 posters reporting mostly mono-institutional experiences on single aspects of the technique from all five continents.

Fabry disease (FD) [OMIM 301500] is an X-linked lysosomal storage disorder caused by a deficiency of the lysosomal enzyme alpha-galactosidase A, resulting in progressive multisystem accumulation of globotriaosylceramide (Gb3). Although the introduction of Enzyme Replacement Therapy (ERT) resulted in a variety of clinical benefits, life-long intravenous (IV) treatment with ERT with an every other week schedule, may interfere with daily life activities and impact on QoL. We report here a multicentric, observational, longitudinal data analysis on a large cohort of 85 Italian FD patients (45 males, 40 females) from 11 out of 20 Italian regions, who received a cumulative number of 4269 home infusions of agalsidase alfa. For the whole cohort, the average duration of home therapy was 1 year and 11 months (range 3 months–4 years and 6 months), and during this period, compliance to treatment (number of infusions performed vs scheduled) reached 100%. The EQ-5 VAS scale was administered to patients to evaluate the self-reported QoL, 58% of patients showing an increase of EQ-5 VAS score at follow up compared to baseline (home treatment start) or remaining stable. A mild increase of average disease severity, measured through Mainz Severity Score Index (MSSI), was found during hospital treatment (p

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a promising method to increase resectability rates of liver tumors. Little has been published about oncological results so far. This report describes clinical evidence regarding a possible effect of ALPPS on tumor recurrence. Ten ALPPS procedures were performed for otherwise non-resectable colorectal liver metastases. Seven of these ten patients had a follow-up of at least 3 months and were analyzed for tumor recurrence. Six of these seven patients had tumor recurrence to the liver. Three of seven patients presented with lung metastases, occurring earlier than liver metastases in two of three cases. One patient with a follow-up of 3 months had no visible recurrent disease, but increasing carcinoembryonic antigen levels. The patient group operable only through ALPPS is at high risk for recurrence and early tumor progression. Still, this new method is the only chance for an oncological treatment strategy including a surgical approach and possibly better outcome.

The authors report on new trends in the multidisciplinary treatment of liver tumors from the 3rd Interdisciplinary Treatment of Liver Tumors Congress in Essen, Germany. Novel aspects of molecular target-oriented therapies of hepatocarcinoma were reported, such as the current position of radiofrequency and microwave ablation of tumors compared with the new electroporation technique. State-of-the-art and new surgical trends in cholangiocarcinoma treatment were also discussed. The correlation of the biological behavior involved in the differentiation of melanomas with the treatment of liver metastasis was better defined. The role of neoadjuvant chemotherapy and combined strategies for colorectal liver metastasis were focused on intra-arterial therapeutic options. New data on neuroendocrine tumor liver metastases were also shared, leading to a better orientation for patient selection for surgical treatment.

Modern colorectal liver metastasis (CRLM) surgery has undergone a very impressive development over the last ten years due to the evolution of methods, techniques and extension of surgical indications. The main limits of surgical CRLM treatment were extension of liver disease, volume and quality of future liver remnant and foreseeable hypertrophy induced by portal vein embolisation or ligation (PVE/PVL) for a possible two-staged hepatectomy. In 2007 Dr. Schlitt, performing the first associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) [1], unconsciously opened Pandora’s box; leading to intense surgical research into two-staged hepatectomies and allowing a further expansion of the resectable pool of liver tumour patients affected by bilobar tumour load. Now, 9 years after the first ALPPS, and after the recently proposed technical evolution named “monosegment ALPPS” [2], we can affirm that we are about to abandon a dogma of liver surgery: for extended liver resection at least 2 liver segments as future liver remnant are necessary; in fact, now this seems to no longer be true. This recent advancement further enhances the concept of liver hypertrophy and the application of ALPPS after agreements of the first consensus meeting [1]. As

Background An alternative mode of interaction with navigation systems for open liver surgery was requested. Surgeons who use such systems are impeded by having to constantly switch between viewing the navigation system screen and the patient during an operation. Methods To this end, an auditory display system for open liver surgery is introduced with support for guiding the tracked instrument towards and remaining on a predefined resection line. To evaluate the method, a clinically orientated user study with 12 surgeons was conducted. Results It is shown in qualitative results from the user study that the proposed auditory display is recognized as a useful addition to the current visual mode of interaction. It was revealed in a statistical analysis that participants spent less time looking on the screen (10% vs. 96%). Accuracy for resection guidance was significantly improved when using auditory display as an additional information channel (0.6 vs. 1.4 mm); however, the overall time for the resection task was shorter without auditory display (47 vs. 24 s). Conclusions By reducing dependence on the visual modality during resection guidance, the auditory display is well suited to become integrated in navigation systems for liver surgery. Copyright © 2012 John Wiley & Sons, Ltd.

The risk of spontaneous bleeding or rupture of liver hemangiomas still remains unknown. The aim of this review was to analyze the problem of spontaneous bleeding or rupture in liver hemangiomas and to identify factors leading to bleeding in these cases. A MEDLINE search was undertaken to identify articles in English, French, German, Italian, and Spanish from 1898 to 2010. Basic data such as age and sex of patients were collected. Additional data such as risk factors or causes of rupture were also analyzed. Cases were divided into spontaneous and non-spontaneous ruptures. A total of 97 cases are described. In 51 of the 97 patients (52.6%) a non-spontaneous rupture was identified. Only in 46 out of the 97 cases (47.4%) was a spontaneous rupture found. Non-spontaneous rupture was significantly more frequent in patients aged

The Authors give an accurate description of a method of incisional hernia repair with an open technique, under local anaesthesia. The aim of this work was to show the feasibility and safety of an open preperitoneal mesh technique, as well as giving a description of technical details and the results of incisional hernia repair under local anaesthesia.Between January 1994 and February 2008, 129 patients underwent an open mesh surgical procedure for incisional hernia. Using some simple selection criteria: maximal diameter of the hernia orifice not greater than 10 cm, the reducibility of the hernia sack, the absence of bowel obstructive symptoms, 71 patients (55.03%) were selected to be submitted to a local anaesthesia procedure, performing an open mesh repair.The median operative time was 101 min. The intra-operative measurement of the hernia defect showed that: in 24 patients (33.8%) it was3 cm, in 37 patients (52.2%) up to 10 cm and in ten patients (14%)10 cm. There were only two conversions to general anaesthesia (2.8%). Among the other 69 patients only four patients (5.7%) showed transient intra-operative bradycardia. All the other 69 patients (97.2%) had immediate postoperative deambulation. Forty-four of them (63.4%) were discharged within 24 h. During follow-up (12-168 months) only two recurrences (2.8%) were registered.This experience clearly shows that local anaesthesia for incisional hernia repair with a open preperitoneal mesh technique is feasible, safe, and effective, having a low intra-operative risk, being cost-effective and showing very good long-term results.

Background: A new approach towards achieving bloodless liver resection is the use of heat coagulative necrosis. The latest stage of this technique is a four-probe device (Habib Sealer), which we used for a variety of resections to find the best indications for the method. Methods: Between 2005 and 2006 we performed 28 liver resections in 20 consecutive patients.The most common indication was metastatic colorectal cancer (75%).We treated a heterogeneous patient collective in terms of tumour localization and extent of resection. Resection was performed after creating a necrotic zone.The device achieved an area of coagulation of 1-cm width in which even larger vessels and bile ducts were safely sealed. Results: Operative spectrum covered atypical resections (8), one- or bisegmentectomies at different locations (15), hemihepatectomies (4) and one extended right hepatectomy. With one exception intra-operative blood loss was lower than 100 mL. Four patients (20%) developed operation-related complications comprising abscess formation at the resection site. Follow-up shows tumour-free survival for 13 of 18 patients 12 months after resection. Conclusion: Liver resection using the sealer device seems safe. In proximity of hilar structures or large vessels the method is not favourable for the fear of thermal damage. Extended resections are possible but not parenchyma saving. Good indications are atypical (deep) resections ‐ especially in Segment IVb.

ABSTRACT The liver-first approach was proposed for the first time in 2006 to obtain resectability of stage IV colorectal cancer patients and complete the therapeutic plan. From then some groups have used this new revolutionary approach reporting promising results. Other alternative strategies have been proposed for metastatic patients. The authors reviewed the literature weighing the pros and cons of each strategy proposed to manage these advanced tumor stages. The therapeutic options are analyzed in the light of oncologic problems and evidence. Also problems, questions and perspectives are given. Even if the ‘liver-first’ approach seems to be a promising strategy, the ideal diagnostic–therapeutic flowchart for metastatic colorectal cancer is still difficult to standardize. The great heterogeneity of this population of patients is one of the main problems. A ‘tailored approach’ philosophy is necessary to calibrate, in a multidisciplinary setting, a case-by-case choice of therapeutic options.

We read with interest the article by Tschuor et al. [1] recently published in your journal and would like to comment on it. Despite being well documented, the authors reported a case of ‘‘rare’’ venous aneurysm. Even if they state an atypical diagnostic workflow leading to an intraoperative ‘‘surprise’’ of an uncommon venous aneurysm finding, we would like to say that looking at the published image of the upper thigh (Fig. 1 of the published article), it is very clear that this ‘‘hernia’’ is surely not an inguinal hernia but could be, in the best hypothesis, a femoral one (even if it seems to be very deep in its location, and usually femoral hernias are clinically diagnosed at the level of Malgaigne line under the inguinal ligament). But also in this case, if (as the author declared in the article) during MRI the sac was spontaneously reducible, it is hardly believable that such a large femoral hernia is so easily ‘‘spontaneously’’ reducible. In fact, from common clinical practice, the hole of femoral hernias is very often a very small defect and often these hernias are not spontaneously reducible like, for example, inguinal ones, and it is not infrequent that such small sacs are incarcerated [2]. Reading the article, it seemed to us very strange that an MRI did not have enough quality to clearly distinguish a venous aneurysm from a hernia’s sac. Furthermore, the preoperative work-up was affected by a mistake in the workflow of diagnostic imaging, in fact, in our opinion, the authors should have first performed a very simple US-scan integrated by color Doppler exploration of the sapheno-femoral junction that is cost-effective and less invasive than MRI. This simple examination can very easily differentiate between a hernia sac, a lipoma, a lymphadenopathy, or venous aneurysm or others [3, 4]! Even an accurate clinical examination (nowadays uncommonly done because of the availability of other technologies) could distinguish between a hernia and a

Background Intrahepatic gallbladder perforation with chronic liver abscess formation was anecdotically reported in the literature. The aim of this work is to report a case of intrahepatic gallbladder perforation and its atypical clinical presentation. Case presentation A 62-year-old male patient came to our observation; his medical history showed intermittent fever up to 39-40°C of about 2 weeks and anorexia, with an overall weight loss of about 12 Kg. Physical examination of the abdomen was negative. An ultrasound of the liver and an abdominal CT angiogram detected a disomogeneous hypoechoic-hypodense area in the 5th segment of the liver. Differential diagnosis between hepatic abscess or gallbladder cancer remained open. A surgical exploration was planned. After laparoscopic exploration, a conversion to open procedure with an atypical resection of the 5th hepatic segment was performed. Histologic examination of the specimen showed an intrahepatic chronic perforation of the gallbladder with intrahepatic abscess. Conclusion To the best of our knowledge, 18 cases have been reported in the literature as a Niemeier type I perforation. Clinical presentation, even in its extreme rarity, is more often acute. Differential diagnosis between gallbladder cancer versus liver abscess remains controversial. Open approach is mandatory in such cases.