1. LAPAROSCOPY AND NATURAL ORIFICE SURGERY: SAFE PRACTICE MODIFICATION

2. Authors Daniel A. Tsin (1), MD The Mount Sinai Hospital of Queens, Long Island City, New York, USA Member of the New European Surgical Academy (NESA);Natural Orifice Surgery working group. Andrea Tinelli (2), MD Department of Obstetric & Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy Member of the New European Surgical Academy (NESA); Natural Orifice Surgery working group. Antonio Malvasi (3), MD Department of Obstetric & Gynecology, Santa Maria Hospital, Bari, Italy Member of the New European Surgical Academy (NESA);Natural Orifice Surgery working group. Fausto Davila (4), MD Universidad Autonoma de Mexico. Facultad de EstudiosSuperiores. Iztacala, Mexico. Ramiro Jesus (4), MD Universidad Autonoma de Mexico. Facultad de EstudiosSuperiores. Iztacala, Mexico. Raul Castro –Perez (5), MD Hospital 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

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

8. Gynecological Surgeries

10. Appendectomies

11. Cholecystectomies

13. Laparoscopy Surveillance View from a secondary port Clear Near miss

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

17. Complications: Laparoscopy Differences and complications during first access between the direct optical entry group (Group A) and the open laparoscopy access group (Group B). Group AGroup B No complications were found in MANOS and in NOTES

18. The surveillance of the first entrance port can be an effective precautionary step. The cumulative experience suggests that using such surveillance in cases involving patients with prior surgery may assist in recognizing complications that might otherwise be missed.

19. PRACTICE MODIFICATION While the search for the safest entry continues,we share our experiencesand recommend whenever possibleto do an endoscopic look at the first entry port site.

20. REFERENCES Tinelli A, Malvasi A, Guido M, Tsin DA, Hudelist G, Stark M, Mettler L. Laparoscopy Entry in Patients with Previous Abdominal and Pelvic Surgery. Surg Innov in press. Tsin DA, Colombero L, LambeckJ,Manolas P. MinilaparoscopyAssisted Natural Orifice Surgery. JSLS 2007;11:24–29. Tsin DA, Castro-Perez R, Davila MR, Davila F. Postoperative Patient Attitudes and Perceptions of TransvaginalCholecystectomy. JLAST 2010; 20: 119-121.

21. REFERENCES Davila F, Tsin DA, Gutierrez L , et al .Transvaginal Single Port Cholecystectomy. SLEPT. 2011;21:203-206 Castro R, Acosta LR, Dopico E, Robaina LE. MANOS: Colecistectomias transvaginales. Reportepreliminar. Cir Esp 2009;85:292–297. Tsin DA, Tinelli A, Malvasi A, Davila F, Jesus R, Castro-Perez R. Laparoscopy and Natural Orifice Surgery: First Entry Safety Surveillance Step. JSLS 2011;15:133-135