Veteran Italy lock Marco Bortolami has been ruled out of the November internationals after fresh complications from a shoulder injury.
The former national captain dislocated his left shoulder during the defeat to Argentina on June 9 and after two initial operations has now undergone a third surgery.
The Italian Rugby Federation said the surgery in Parma was a success but he needs to wear a brace for at least a month and will be out of action for longer than that.
Italy play Tonga on November 10 before facing New Zealand a week later and Australia on November 24.
The news also comes as a blow to RaboDirect PRO12 new boys Zebre, who will be without the 32-year-old forward's services for much of the first half of the season.
Bortolami was due to captain Zebre in their first season in the league.