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Highlights • Trocar site hernia (TSH) is an uncommon complication of robot-assisted laparoscopy. • The surgical aspects are the trocar size and positioning, the duration of the surgery, and the fascial closure. • Surgical guidelines suggest fascial closure for a laparoscopic trocar site port that is 10 mm or larger. • There are no established rules for robotic surgery. • There is a need to pay particular attention in cases that involve a long surgical operation and to the sites at which to position trocars., Over the last twenty years, robotic surgery has become an increasingly important form of surgical intervention. However, it can have complications. Trocar site hernia (TSH), also known as port site hernia (PSH), is an uncommon complication, but in the case of bowel incarceration or strangulation it can cause significant morbidity. The lateral trocar sites usually do not need fascial closure, given their low susceptibility to hernia development. In this paper, we present a rare case of an incarcerated TSH from an 8 mm left lateral port after robotic colposacropexy. The patient was a 74-year-old woman with fourth-degree vaginal vault prolapse. She underwent robot-assisted colposacropexy and adnexectomy and was eventually discharged 3 days after surgery, with flatus. A few hours later, the woman developed generalized malaise and acute abdominal pain in the lower left quadrant, with no flatus or bowel movements. CT imaging revealed a small bowel dilatation with a transition point along the left lateral 8 mm trocar site. Laparotomy confirmed an incarcerated ischemic small bowel loop. This required a surgical 40 cm small bowel resection. Although uncommon, TSH is an important clinical entity to recognize after minimally invasive surgery. While it is known that a trocar site port of 10 mm or more does require fascial closure, it is not known whether the same is true of lateral 8 mm sites. Further studies are needed to reconsider the importance of lateral trocar site port fascial closure after robot-assisted surgery.

Background: In the last few decades many studies have investigated the role of major salivary glands ultrasound (SGUS) in the diagnostic work-up of patients with suspected primary Sjogren’s syndrome (pSS). Recent development of ultra-high-resolution ultrasound systems (UHFUS), with frequencies as high as 70 MHz and capability resolution as fine as 30 μm, has permit new diagnostic applications to a variety of superficial targets including labial salivary glands (LSGs). To date, however, no information are available regarding the use of UHFUS for the study of LSGs in humans. Objectives: To evaluate the feasibility and the diagnostic accuracy of UHFUS of LSGs in patients with suspected SS and to assess the correlations between LSG histopathology, UHFUS and SGUS. Methods: Consecutive patients with clinically suspected pSS were included in this study. All patients underwent a complete diagnostic work-up including conventional SGUS and LSG biopsy. The same expert pathologist calculated for all the samples the focus score (FS), number of foci and evaluated the presence of ectopic germinal centers (GCs). UHFUS of LSG was performed by specialized radiologists scanning first the central compartment of the inferior lip, and then both peripheral compartments. The following parameters were evaluated: distribution of the glands, parenchymal inhomogeneity (score 0-3, from normal to evident), fibrosis and eco color-Doppler vascular pattern and grade of vascular intensity. Results: We included 32 patients with suspected pSS. At the end of the work-up, pSS diagnosis was confirmed in 12/32 (37.5%) cases. No differences between pSS patients and no-SS sicca controls were observed in UHFUS findings related to LSG distribution and eco color-Doppler vascular parameters. By contrast, pSS patients presented statistically significant differences in peripheral UHFUS inhomogeneity (p=0.006), and a higher degree of fibrosis (p=0.01). Considering a score ≥2 in parenchymal inhomogeneity as suggestive for pSS, UHFUS appeared less specific than conventional SGUS (UHFUS Sp=70% vs SGUS Sp=95%) but more sensitive (UHFUS Se=83.3% vs SGUS Se = 58.3%). In addition, when we investigated the relationship between UHFUS, SGUS and LSG histopathology we found that the correlation coefficients between UHFUS inhomogeneity and LSG FS (UHFUS r=0.706** vs SGUS r=0.393*), number of foci (UHFUS r=0.712** vs SGUS r=0.445*), and number of ectopic GCs (UHFUS r=0.525** vs SGUS r=0.141), were significantly higher than those observed with conventional SGUS. Conclusion: the application of UHFUS to the study of LSG in pSS appeared feasible and sensitive. Because of the anatomical details obtained with this technique and its stronger correlation with LSG histopathology, UHFUS might offer unique advantages over the existing major salivary gland imaging modalities in pSS assessment. Disclosure of Interests: Chiara Baldini: None declared, Francesco Ferro: None declared, Veronica Iodice: None declared, Rossana Izzetti: None declared, Valentina Donati: None declared, Silvia Fonzetti: None declared, Teresa Oranges: None declared, Valentina Dini: None declared, Dania Cioni: None declared, Nicoletta Luciano: None declared, Rosa Maria Bruno: None declared, Marta Mosca Paid instructor for: GlaxoSmithKline, Lilly, UCB, Saverio Vitali: None declared, Davide Caramella: None declared

A traumatic diaphragmatic injury (TDI) is a severe lesion that may be caused both by blunt and penetrating trauma, with ratio being different from country to country and derived from social and economic factors. Despite chest X-ray may directly or indirectly suggest the possibility of TDI, whole-body computed tomography represents the examination of choice to demonstrate such a lesion. TDI detection is fundamental in order to avoid delayed critical complications that may be fatal, like visceral intrathoracic herniation with risk of acute respiratory failure and organ strangulation. This is the reason why early diagnosis and prompt surgical repair are mandatory. Nevertheless, TDI often remains undiagnosed depending on the presence of subtle clinical/radiological signs and very frequent concomitant multiorgan life-threatening lesions that overshadow the diaphragm involvement. Therefore, the emergency radiologist should be confident about specific and nonspecific signs of TDI and get familiar with the mechanism of injury, in order to maintain a high degree of suspicion and inform both the emergency clinician and surgeon in time.