Care Settings



Health care services and their related costs are continuously increasing, due to an ageing population and the spread of chronic conditions. Since the resources are limited, the only way to allow a sustainable system is to modify current protocols and regimes, improving organizational policies and procedures.

This has led to an evolution of conventional hospital stay, and to the birth of Day Care Services and Day Surgery. Moreover, the adoption of new surgical pathways, such as ERAS and fast track, and a careful patient selection have contributed to reduce post-operative complications and length of hospital stay, decreasing hospitalization costs.

Abdominal wall surgery gave an important impulse to this evolution, thanks to its innovations and specific characteristics, as the advent of prosthetic and tension-free techniques, and the use of local or peripheral nerve block anaesthesia. These improvements have allowed to achieve early recovery of function, shortening length of hospital stay.

The Italian reimbursing system, based on DRG, still has to adapt to these new pathways, in order to preserve the standards achieved today.

The hope is that through an appropriate management of care settings, a strong prevention policy and a wise use of high-tech, day surgery will be safe for more and more people, and sustainable for the health care system.


Health care delivery Surgical care Day surgery Hospital costs 


  1. 1.
    Milani RV, Lavie CJ. Health care 2020: reengineering health care delivery to combat chronic disease. Am J Med. 2015;128(4):337–43.CrossRefGoogle Scholar
  2. 2.
    Greco DP, Amatucci F, Padula GA. Treatment cost reimbursement from the healthcare systems. In: Inguinal hernia surgery. Milano: Springer; 2017. p. 193–205.. (Updates in Surgery).CrossRefGoogle Scholar
  3. 3.
    Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292–8.CrossRefGoogle Scholar
  4. 4.
    Roulin D, Donadini A, Gander S, Griesser A-C, Blanc C, Hübner M, et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg. 2013;100(8):1108–14.CrossRefGoogle Scholar
  5. 5.
    Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430–43.CrossRefGoogle Scholar
  6. 6.
    Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011;2:CD007635.Google Scholar
  7. 7.
    Lawal AK, Rotter T, Kinsman L, Sari N, Harrison L, Jeffery C, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014;3:103.CrossRefGoogle Scholar
  8. 8.
    European Pathway Association. Care pathways [Internet]. Available from: Cited 11 Mar 2018.
  9. 9.
    De Bleser L, Depreitere R, De Waele K, Vanhaecht K, Vlayen J, Sermeus W. Defining pathways. J Nurs Manag. 2006;14(7):553–63.CrossRefGoogle Scholar
  10. 10.
    de Luc K. Developing care pathways: the handbook. 1st ed. Abingdon: Routledge; 2000. p. 192.Google Scholar
  11. 11.
    Mathis MR, Naughton NN, Shanks AM, Freundlich RE, Pannucci CJ, Chu Y, et al. Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology. 2013;119(6):1310–21.CrossRefGoogle Scholar
  12. 12.
    Gandhimani P, Jackson IJB. UK guidelines for day surgery. Surg Oxf. 2006;24(10):346–9.Google Scholar
  13. 13.
    Revell MA. Role of research in best practices. Nurs Clin North Am. 2015;50(1):19–32.CrossRefGoogle Scholar
  14. 14.
    Davidson J. Why a column on ambulatory best practices? AORN J. 2014;99(5):612–5.CrossRefGoogle Scholar
  15. 15.
    Ferre F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, et al. Italy: health system review. Health Syst Transit. 2014;16(4):1–168.PubMedGoogle Scholar
  16. 16.
    Fischer K. Ambulatory operations and day surgery in the hospital--financing from the viewpoint of the hospital. Zentralbl Chir. 1994;119(7):470–6.PubMedGoogle Scholar
  17. 17.
    Greco DP. Dal protocollo alla tariffa: un percorso per affrontare e gestire le problematiche dei costi della sanità. Milan: FrancoAngeli; 2000. p. 196.Google Scholar
  18. 18.
    Cochrane AL. Effectiveness and efficiency: random reflections on health services. Nuffield Provincial Hospitals Trust; 1972. p. 112.Google Scholar
  19. 19.
    Kurzer M, Belsham PA, Kark AE. The Lichtenstein repair. Surg Clin North Am. 1998;78(6):1025–46.CrossRefGoogle Scholar
  20. 20.
    Callesen T. Inguinal hernia repair: anaesthesia, pain and convalescence. Dan Med Bull. 2003;50(3):203–18.PubMedGoogle Scholar
  21. 21.
    Spallitta SI, Termine G, Zappulla A, Greco V, Compagno GM, Lo Iacono I, et al. Tension-free hernioplasty in the treatment of inguinal hernia in the adult: our experience with local anesthesia and a review of the literature. Minerva Chir. 1999;54(9):573–89.PubMedGoogle Scholar
  22. 22.
    Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev. 2011;3:CD007781.Google Scholar
  23. 23.
    Barbaros U, Asoglu O, Seven R, Erbil Y, Dinccag A, Deveci U, et al. The comparison of laparoscopic and open ventral hernia repairs: a prospective randomized study. Hernia. 2007;11(1):51–6.CrossRefGoogle Scholar
  24. 24.
    Cornette B, De Bacquer D, Berrevoet F. Component separation technique for giant incisional hernia: a systematic review. Am J Surg. 2018;215(4):719–26.CrossRefGoogle Scholar
  25. 25.
    Kenchadze G, Pipia I, Demetrashvili Z, Botezatu A, Marakutsa E, Raileanu R, et al. Incisional hernia: plastic aspects, component separation, technical details & pediatrics. Hernia. 2015;19(Suppl. 1):S187–94.CrossRefGoogle Scholar
  26. 26.
    Eriksson A, Rosenberg J, Bisgaard T. Surgical treatment for giant incisional hernia: a qualitative systematic review. Hernia. 2014;18(1):31–8.CrossRefGoogle Scholar
  27. 27.
    Walker PA, May AC, Mo J, Cherla DV, Santillan MR, Kim S, et al. Multicenter review of robotic versus laparoscopic ventral hernia repair: is there a role for robotics? Surg Endosc. 2018;32(4):1901–5.CrossRefGoogle Scholar
  28. 28.
    Arcerito M, Changchien E, Bernal O, Konkoly-Thege A, Moon J. Robotic inguinal hernia repair: technique and early experience. Am Surg. 2016;82(10):1014–7.PubMedGoogle Scholar
  29. 29.
    Allison N, Tieu K, Snyder B, Pigazzi A, Wilson E. Technical feasibility of robot-assisted ventral hernia repair. World J Surg. 2012;36(2):447–52.CrossRefGoogle Scholar
  30. 30.
    Decreto Ministero della Salute 18 ottobre 2012. GU Serie Generale n.23 del 28-01-2013—Suppl. Ordinario n.8):
  31. 31.
    Antoniou SA, Agresta F, Garcia Alamino JM, Berger D, Berrevoet F, Brandsma H-T, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia. 2018;22(1):183–98.CrossRefGoogle Scholar
  32. 32.
    Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society Guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1–24.CrossRefGoogle Scholar
  33. 33.
    Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.CrossRefGoogle Scholar
  34. 34.
    Takebayashi K, Matsumura M, Kawai Y, Hoashi T, Katsura N, Fukuda S, et al. Efficacy of transversus abdominis plane block and rectus sheath block in laparoscopic inguinal hernia surgery. Int Surg. 2015;100(4):666–71.CrossRefGoogle Scholar
  35. 35.
    Cohen DD, Dillon JB. Anesthesia for outpatient surgery. JAMA. 1966;196(13):1114–6.CrossRefGoogle Scholar
  36. 36.
    Capdevila X, Dadure C. Perioperative management for one day hospital admission: regional anesthesia is better than general anesthesia. Acta Anaesthesiol Belg. 2004;55(Suppl):33–6.PubMedGoogle Scholar
  37. 37.
    Stark GB, Horch R, Tánczos E. Biological matrices and tissue reconstruction. Berlin: Springer-Verlag; 1998. p. 328.CrossRefGoogle Scholar
  38. 38.
    Pérez-Köhler B, Bayon Y, Bellón JM. Mesh infection and hernia repair: a review. Surg Infect. 2016;17(2):124–37.CrossRefGoogle Scholar
  39. 39.
    Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg Lond Engl. 2014;12(10):1105–14.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Day&Week Surgery UnitOspedale Niguarda Ca’ GrandaMilanoItaly
  2. 2.Department of SurgeryNiguarda HospitalMilanItaly
  3. 3.University of MilanMilanItaly

Personalised recommendations