This document discusses modifications to laparoscopic and natural orifice surgery techniques to enhance safety. It describes experiences with 168 laparoscopic procedures where the first entry port was observed for complications, 145 minilaparoscopy assisted natural orifice surgeries, and 3 natural orifice transvaginal endoscopic surgeries. No complications were observed when surveilling the first entry port. The authors recommend whenever possible to endoscopically examine the first entry port site to recognize any potential complications.

1. LAPAROSCOPY AND NATURAL ORIFICE SURGERY: SAFE PRACTICE MODIFICATION

2. AuthorsDaniel A. Tsin (1), MDThe Mount Sinai Hospital of Queens, Long Island City, New York, USAMember of the New European Surgical Academy (NESA);Natural Orifice Surgery working group.Andrea Tinelli (2), MDDepartment of Obstetric & Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, ItalyMember of the New European Surgical Academy (NESA); Natural Orifice Surgery working group.Antonio Malvasi (3), MDDepartment of Obstetric & Gynecology, Santa Maria Hospital, Bari, ItalyMember of the New European Surgical Academy (NESA);Natural Orifice Surgery working group.Fausto Davila (4), MDUniversidad Autonoma de Mexico. Facultad de EstudiosSuperiores. Iztacala, Mexico.Ramiro Jesus (4), MDUniversidad Autonoma de Mexico. Facultad de EstudiosSuperiores. Iztacala, Mexico.Raul Castro –Perez (5), MDHospital Universitario Abel SantamaríaCuadrado. Pinar del Río. Universidad de CienciasMédicas de Pinar del Río, Cuba

3. None of the currently available entry forms into the abdominal cavity are free of complications.

4. We are sharing information regarding the surveillance of the first entrance port (FEP) in Laparoscopy , Minilaparoscopy Assisted Natural Orifice Surgery and Natural Orifice TransvaginalEndoscopy Surgery

5. Patients and Methods 168 women with previous abdominal surgery underwent laparoscopic surgery: 86 were assigned to abdominal DOE (Group A), and

6. 82 to Open Laparoscopy (OL) (Group B).

7. 145 patients underwent transvaginalMinilaparoscopy Assisted Natural Orifice Surgery (hybrid) 3 patients underwent pure natural orifice transvaginal endoscopic surgery (pure). Procedures LAPAROSCOPY

8. Gynecological Surgeries

9. MINILAPAROSCOPY ASSISTED NATURAL ORIFICE SURGERY (MANOS)Gynecological Surgeries

10. Appendectomies

11. Cholecystectomies

12. NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)CholecystectomiesThe laparoscopies were done either by accessing the peritoneal cavity using a Direct Optical Entry (DOE) that employed a bladeless trocar with an optical viewing port (Endopath or Endopath Xcel; Ethicon EndoSurgery, Cincinnati, OH, USA) without previous pneumoperitoneum. (Group A) OR by the open entry method using the Hasson technique (Ethicon Endo-Surgery, Cincinnati, OH, USA) (Group B).

13. Laparoscopy SurveillanceView from a secondary portClear Near miss

14. Minilaparoscopy Assisted Natural Orifice Surgery View Via a secondary abdominal or vaginal port

15. Minilaparoscopy Assisted Natural Orifice Surgery First Entry Port134 Minilaparoscopy or Posterior Colpotomy

16. 11 Circular Colpotomy (Simultaneous Vaginal Hysterectomy) NOTESA retro view