Open Entries Research Articles

Barriers to research usage for Saudi Arabia's emergency medical technicians

In Saudi Arabia, Emergency Medical Technicians (EMTs) play a pivotal position in prehospital care, yet several obstacles obstruct their powerful usage of research findings. Despite the growing emphasis on evidence-based total exercise in healthcare, Saudi EMTs stumble upon multifaceted demanding situations hindering the uptake of studies of their clinical exercise. These hurdles encompass various domain names, which include confined access to updated research materials because of subscription charges and language boundaries, inadequate education in critical appraisal capabilities and studies interpretation, a loss of organizational assistance, and time constraints inside their disturbing work schedules. Moreover, the healthcare machine's cultural factors and hierarchical structures can deter EMTs from thinking about established practices or searching out new, proof-based methods. Addressing these barriers necessitates tailor-made interventions and supplying open entry to pertinent research, imparting focused education applications in studies literacy, fostering a supportive organizational lifestyle that values and encourages research utilization, and emphasizing the relevance of evidence-primarily based exercise in improving patient consequences. By mitigating these barriers, Saudi Arabia can empower its EMTs to integrate modern-day research findings into their scientific decision-making, improving the quality and efficacy of emergency medical services in the area in the long run.

Taming of Furfurylidenes by Chiral Bismuth‐Rhodium Paddlewheel Catalysts. Preparation and Functionalization of Optically Active 1,1‐Disubstituted (Trifluoromethyl)cyclopropanes

AbstractAlthough 2‐furyl‐carbenes (furfurylidenes) are prone to instantaneous electrocyclic ring opening, chiral [BiRh]‐paddlewheel complexes empowered by London dispersion allow (trifluoromethyl)furfurylidene metal complexes to be generated from a bench‐stable triftosylhydrazone precursor. These reactive intermediates engage in asymmetric [2+1] cycloadditions and hence open entry into valuable trifluoromethylated cyclopropane or ‐cyclopropene derivatives in optically active form, which are important building blocks for medicinal chemistry but difficult to make otherwise.

Taming of Furfurylidenes by Chiral Bismuth-Rhodium Paddlewheel Catalysts. Preparation and Functionalization of Optically Active 1,1-Disubstituted (Trifluoromethyl)cyclopropanes.

Although 2-furyl-carbenes (furfurylidenes) are prone to instantaneous electrocyclic ring opening, chiral [BiRh]-paddlewheel complexes empowered by London dispersion allow (trifluoromethyl)furfurylidene metal complexes to be generated from a bench-stable triftosylhydrazone precursor. These reactive intermediates engage in asymmetric [2+1] cycloadditions and hence open entry into valuable trifluoromethylated cyclopropane or -cyclopropene derivatives in optically active form, which are important building blocks for medicinal chemistry but difficult to make otherwise.

705 Assessment of a Novel Low-Cost Abdominal Box Simulator for Laparoscopic Skills Training

Abstract Aim To create a low-cost abdominal box simulator and assess its validity for Hassan’s entry technique and visiport. Method A low-cost abdominal box simulator was created using a metal box skeleton. This was covered in a layer of cling-film simulating the peritoneum. Red and blue tubing was placed over this creating the inferior epigastric vessels. A posterior rectus sheath was created on either side using a white cotton sheet whilst thick red woollen socks were used to simulate the rectus abdominus muscles. The entire surface was then wrapped in a thick canvas to simulate the anterior rectus sheath. Finally, a commercial skin with subcutaneous tissue was affixed and the umbilicus demarcated using a pen. This simulator was used by 30 surgical trainees (ST3 to ST7) attending a laparoscopic skills course who were asked to provide feedback on the simulator for both Hassan’s entry technique, visiport entry and the introduction of secondary ports. Results The simulator was rated 10/10 for validity as well as ease of use for Hassan’s open entry technique, visiport and secondary port insertion by all 30 of the trainees. Feedback highlighted that using the simulator trainees were able to see all layers of the abdomen and gain excellent haptic feedback. The model was described as realistic as trainees were able to identify each layer of the abdomen as they performed open or visiport entry. Conclusions A low-cost abdominal box simulator can easily be reproduced using our technique and used to train trainees effectively.

The Benefits of the Disabled Veterans’ Scholarship Fund at the Open University, UK

The Disabled Veterans’ Scholarship Fund (DVSF) was set up by the United Kingdom (UK) Open University (OU) to meet the needs of those who were injured in UK military service or medically discharged by providing 100 free places to study for a degree. The purpose of the study was to ascertain the experience of study and the benefits of the scholarship fund for veteran scholars, as well as identify what they needed to be successful in their studies. This study took a qualitative participatory research approach, which involved 24 semistructured telephone interviews with 14 veteran scholars over a period of 5 months, followed by a live online event to feedback the findings of the interviews and look to the future of study for the veterans. The two main benefits of the scholarship fund were that the OUs open entry system meant that a lack of formal qualifications was not a barrier to study, and through the DVSF, study was free. Although the university offered a range of supportive services there was a perceived misalignment between the support the veterans were used to during their military service and the support that was provided by the OU, which led to frustrations. Despite this finding there was a perception by the support service at the OU that the veterans were a hard-to-reach group, and recognition that a community of support was needed. Both issues were partly addressed through an online student hub live event. The support services at the OU worked alongside the evaluation project team to devise a bespoke programme that brought many of the veterans together for the first time. The DVSF has been successful in providing study to disabled veterans. The next step is to build a community of peer support for the veterans as they progress in their studies to meet their career goals.

The Benefits of the Disabled Veterans’ Scholarship Fund at the Open University, UK

The Disabled Veterans’ Scholarship Fund (DVSF) was set up by the United Kingdom (UK) Open University (OU) to meet the needs of those who were injured in UK military service or medically discharged by providing 100 free places to study for a degree. The purpose of the study was to ascertain the experience of study and the benefits of the scholarship fund for veteran scholars, as well as identify what they needed to be successful in their studies. This study took a qualitative participatory research approach, which involved 24 semistructured telephone interviews with 14 veteran scholars over a period of 5 months, followed by a live online event to feedback the findings of the interviews and look to the future of study for the veterans. The two main benefits of the scholarship fund were that the OUs open entry system meant that a lack of formal qualifications was not a barrier to study, and through the DVSF, study was free. Although the university offered a range of supportive services there was a perceived misalignment between the support the veterans were used to during their military service and the support that was provided by the OU, which led to frustrations. Despite this finding there was a perception by the support service at the OU that the veterans were a hard-to-reach group, and recognition that a community of support was needed. Both issues were partly addressed through an online student hub live event. The support services at the OU worked alongside the evaluation project team to devise a bespoke programme that brought many of the veterans together for the first time. The DVSF has been successful in providing study to disabled veterans. The next step is to build a community of peer support for the veterans as they progress in their studies to meet their career goals.

8605 Gynecologic Laparoscopy in the Bariatric Patient: A Retrospective Review of Abdominal Access and Associated Complications

<h3>Study Objective</h3> To provide clinical direction on laparoscopic abdominal entry techniques in women with known history of laparoscopic Roux-en-Y Gastric Bypass (RYGB) undergoing gynecologic surgery and to identify any associated complications. <h3>Design</h3> Retrospective Chart Review and Case Series. <h3>Setting</h3> Community-based tertiary care medical center. <h3>Patients or Participants</h3> All patients who underwent RYGB between 2013 and 2020 and had a subsequent gynecologic procedure. <h3>Interventions</h3> Abdominal access. <h3>Measurements and Main Results</h3> Thirty-one patients were identified, of which 18 had an adnexal surgery and 13 a hysterectomy. At time of surgery, the mean age was 44 years and body mass index was 32 kg/m². The average interval time from RYGB to gynecologic surgery was 29 months. The majority of women (71%) had additional abdominal surgeries, among them 82% had prior laparotomies. Three entry sites were identified at the initial attempt to access the abdominal cavity; umbilical (71%), left upper quadrant (LUQ, 26%) and left lower quadrant (LLQ, 3%). Closed entry technique using the Veress needle was the most commonly used entry technique (68% versus 29% for optical trocar entry and 3% for open entry). There were no injuries resulting from abdominal access irrespective of the entry site or technique chosen. However, access was unsuccessful in 25% (2 out of 8) of the cases when attempted in the LUQ, resulting in conversion to alternative entry sites. <h3>Conclusion</h3> Successful and safe abdominal access in the bariatric patient can sometimes be challenging and preoperative surgical planning is essential. While no injuries during entry were reported regardless of site chosen, closed entry at the umbilicus using the Veress needle was the technique the most practiced and was associated with fewer attempts and conversions to alternative sites as compared to LUQ entry.

An Australian Case Study of Mandatory Education for the Bus and Coach Industry

The changing regulatory environment in which public transportation is provided has generated a need for different forms of bus operations and management. This article discusses the introduction and development of a compulsory education program for bus and coach operators in Victoria, Australia. The Victorian government introduced a new system of operator (manager or owner in U.S. terminology) accreditation through the Public Transport Competition Regulations (1999). The accreditation process requires individual managers and owners to successfully complete the transport management course in bus and coach operations.The development and introduction of the course is a significant change for the industry and exists in a challenging sociopolitical environment. The course is designed to help people make the best use of new opportunities, such as open entry and competition promoted by the legislation. The majority of operators who have already completed the course found it extremely helpful, useful, and enjoyable. On the other hand, a “fear of the unknown” for some operators has resulted in resentment and aggression in a few cases. The article describes the challenges of working with operators as they move away from a protected environment toward accreditation.

Innovation Capability and Open Innovation for Small and Medium Enterprises (SMEs) Performance: Response in Dealing with the COVID-19 Pandemic

The current business environment requires every organization or company to achieve optimal performance and maintain it. Innovation capability and open innovation practices play a critical role in improving organizational performance. However, their role in improving Small and Medium Enterprises (SMEs)’s performance, especially during the COVID-19 pandemic, still needs to be identified further. Thus, this study conducts empirical research elaborating intrinsic factors of innovation capability, as well as the influence of open innovation on organizational efforts, i.e., how SMEs achieve optimal performance during the COVID-19 pandemic. In this research model, 206 respondents were gathered and given a reearch questionnaire. The respondents are the owner of batik SMEs located in several regions in Indonesia. PLS-SEM is used to test the data, and the result of this study shows that all hypotheses developed in this study are accepted, i.e., SMEs’ innovation capability and open innovation practices significantly influence financial and operational performance. The results show that in batik SMEs, the ability to innovate and open innovation, especially open entry innovation, can facilitate greater organizational performance. Therefore, batik SMEs woud benefit from initiatives and opportunities that improve their abilities in open innovation.

How to protect your money in the face of rising inflation

How to protect your money in the face of rising inflation

Chestvovanie inklyuzivnosti: organizatsiya i ritual sporta massovogo uchastiya

We describe the best organizational practices, ceremonies, and rituals of mass participation sports events. In addition to participant observation of endurance races in distance running, triathlon, cycling, swimming, and cross-country skiing between 2003 and 2019, statistical and document analysis was used as the research methodology. Special focus was placed on triathlon in Europe. We argue that the phenomenon of mass participation sports is a consequence of the Expressive model of sports (EMS) as a social construct shared by the community. We explain how the EMS is implemented in the organization of events through rituals, conventions, and institutions. Firstly, within the EMS, the race finish is recognized as an achievement by the organizers and the participant’s community. Secondly, the EMS focuses on ordinary, non-elite amateurs as main event participants. This means an open entry to participation, with no selection by skill level; permissive time limits; equal distances, entry fees, and service levels for both elite and non-elite athletes; a joint festival and event venue; competition schedule comfortable for amateurs (non-elite races on the weekend). Thirdly, the EMS revises the linear ranking of competitions through a new hierarchy model, an age-weighted presentation of results, and an inclusive celebration ritual. This includes the grouping of athletes into ordinary amateurs with no reward and elite/professionals, who compete for absolute an ranking and/or prizes, a broad division of amateurs by age groups (95–99, 90–94, 85–89 and down to 20–24, 15–19) and the celebration of the oldest athletes and last finishers. The theoretical framework combines the insights from the civilization process, evolutionary and symbolic anthropology. Since endurance races are seen as rites of passage and liminal processes, we emphasize the importance of rituals as a means of a reconciliation of communitas.

The voice of students from a Black, Asian or minority ethnic background

The Open University is a large, distance-learning university, serving all four nations of the United Kingdom (UK) and provides education for most of its students through open entry, meaning that no prior qualifications are necessary. At the OU, we have a low percentage of students who come from a black, Asian or minority ethnic (BAME) background, ranging from 4% to 13% depending on their programme of study. However, due to the high student population at the Open University, that low percentage amounts to thousands of students. We were keen to hear from our BAME students, as we are aware of a challenging awarding gap between these students and white students. We ran three focus groups with a total of ten students from a BAME background, and asked about issues such as being valued, inclusion, a sense of belonging and feeling represented. This was the first time that BAME students had been asked about their views in this way. We found that although there were positive insights, students were uncomfortable engaging in forums, lacked a sense of belonging and did not feel represented in the curriculum. By encouraging these students to give voice to their concerns, we heard, for the first time, some of the issues they are dealing with that need to be addressed.

Comparison of the Outcomes of Direct Trocar Insertion with Modified Open Entry in Laparoscopic Surgery

Comparison of the Outcomes of Direct Trocar Insertion with Modified Open Entry in Laparoscopic Surgery

Oncologist management of NTRK fusion-positive NSCLC improves after virtual patient simulation participation.

e23008 Background: Although relatively rare, neurotrophic receptor tyrosine kinase (NTRK) fusions, represent a clinically relevant subgroup of NSCLC that can derive benefit from targeted therapies. Relatively quick and durable responses have been achieved with these targeted therapies in advanced NSCLC and intracranial activity has also been observed. The objective of this study was to determine if an online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention improved performance of oncologists in using appropriate strategies to diagnose and manage patients with NTRK fusion-positive advanced NSCLC. Methods: The CME intervention consisted of two patient cases presented in a VPS platform that allowed learners to order lab tests, diagnoses and treatments in a manner matching the scope and depth of actual practice. Clinical decisions made by the learners using open field entries within an EHR interface were analyzed and, after each decision, tailored clinical guidance (CG) was provided based on current evidence and expert recommendation. Learner decisions were collected post-CG and compared with each user’s baseline (pre-CG) data using a McNemar’s test to determine P values. Results were then aggregated for the two cases based on clinical decisions and stratified by practice setting. The activity posted July 31, 2020; data were collected through December 1, 2020. Results: Overall significant improvements were seen after CG in clinical decisions made by oncologists in both the community and academic settings [reported as % absolute improvement (% correct pre-CG vs % correct post-CG); P value]. Conclusions: This analysis demonstrated that VPS that immerses and engages oncologists in an authentic and practical learning experience can significantly improve evidence-based clinical decisions related to the diagnosis and management of patients with NTRK fusion-positive advanced NSCLC. Despite the improvements, additional educational activities are needed to address any residual gaps and further increase oncologists’ ability in this clinical setting.[Table: see text]

Landrace added value and accessibility in Europe: what a collection of case studies tells us

In the actual climate change scenario, in situ conservation of plant genetic resources for food and agriculture can significantly contribute broadening the diversity of our food system as well as increasing its resilience; nevertheless, landrace cultivation has been dramatically reduced in the last decades all over Europe. One of the most effective approaches to counteract the loss of landrace diversity in situ is facilitating its use. Aims of this study were to (i) describe how in situ maintenance of landraces occurs in different agro-environmental conditions in Europe and (ii) identify the main factors influencing landrace added values and accessibility as means to increase their adoption by new farmers. To the purpose, a collection of 95 case studies of both garden and open field landraces maintained in situ was analysed. A first description was obtained by classifying the information into 18 purposely defined categories. Data on landraces added values and accessibility were further transformed into weighted variables; the derived quantitative scores were then used as dependent variables in univariate and multivariate analyses. Results showed that farmers alone are still the main actors maintaining landraces in situ across different European biogeographical regions, mainly carrying out their activity under organic or low-input conditions, often in marginal areas. Results of the multivariate analysis showed that (i) type of actor involved in the multiplication, (ii) the main use of the product and (iii) presence of promotion actions significantly affect garden landraces added value and accessibility; presence of promotion actions was the only factor affecting added value of open field entries. Evidence arising from this work can contribute to the establishment of a fruitful ground of discussion for future European policies and strategies to protect and increase landrace use.

Economic crisis in mass representations of Russians

During the post-Soviet period, Russians have experienced several economic crises, which have become a prism for assessing the political situation in the country and the direction of its development. In this article, based on mass polls data by the Public Opinion Foundation (FOM) and Russian Public Opinion Research Center (VCIOM) in 2019-2020, the author has reconstructed public perceptions of the economic crisis, identified the groups more inclined to admit the crisis in the country, described adaptive mechanisms they used, and assessed if the feeling of crisis affect the public trust in political institutions. A quantitative textual analysis of the open entry responses concerning the characteristics of the economic crisis shows that it is consistently associated with the gap between available and desired levels of consumption and economic security, rather than a sharp decline in macroeconomic indicators. Rising prices, low living standards and low wages are the most frequent indicators of the crisis in the responses. Respondents in the low-income categories and younger cohorts are the most susceptible to the crisis. Adaptation mechanisms had already begun to form on the eve of the main wave of the pandemic in March 2020, but the increased level of uncertainty about the future determined the demand for trustful information on the state of affairs in the economy. The study also shows that the feeling of crisis is associated with the decreased distrust of governmental bodies. In general, the work demonstrates the importance of studying subjective assessments of well-being and their role in structuring information about processes in politics and economy.

Presentation of an open entry technique for laparoscopy through a congenital defect in the umbilical fascia

ObjectiveWe present and describe a modification of the Hasson open entry technique to gain access to the abdominal cavity for laparoscopy in which a congenital defect in the umbilical fascia is identified for entry into the peritoneum and insertion of the primary port. MethodsA single centre, prospective, observational, pilot study has been conducted with no change in clinical practice. Data regarding the success of the technique, time to laparoscope insertion, complications and patient risk factors were collected and presented. ResultsThe team enrolled 114 patients that had the St Helier technique attempted for entry in the abdominal cavity. Entry was achieved for all patients. The technique had 82.5 % success rate while this reduced to 65 % in patients with previous laparoscopies. The mean time to insertion of the laparoscope was 220 s, and there was no significant difference in success with variation in BMI. We recorded no minor or significant intra-operative complications. The superficial wound infection rate was 2.6 % with no other postoperative complications identified at 6-week follow-up. ConclusionsThe presented technique is a safe and successful method of laparoscopic entry with a presumed shorter time until laparoscope insertion than other techniques used. The absence of complications could be attributed to the avoidance of sharp dissection of the umbilical fascia. The less invasive nature could reduce risks of hematoma, infection or hernia that are associated with the standard entry techniques used. Formal studies of long-term outcomes are required, as well as evaluating use in emergency and contaminated cases.

Maintenance of Remission With Tofacitinib Therapy in Patients With Ulcerative Colitis

Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of ulcerative colitis (UC). The efficacy and safety of tofacitinib in patients with moderate to severe UC, up to 1 year, have been reported. We investigated maintenance of efficacy in patients in remission after 52 weeks of maintenance treatment in the pivotal phase 3 study (OCTAVE Sustain); these patients received open-label, long-term treatment with tofacitinib 5 mg twice daily. Patients with moderate to severe UC who completed a 52-week, phase 3 maintenance study (OCTAVE Sustain) were eligible to enroll into the ongoing, phase 3, multicenter, open-label, long-term extension (OCTAVE Open). We analyzed data from 142 patients who were in remission following tofacitinib treatment in OCTAVE Sustain who received tofacitinib 5 mg twice daily during OCTAVE Open. We assessed efficacy (including remission [based on total Mayo score], endoscopic improvement, clinical response, and partial Mayo score up to month 36 of OCTAVE Open) and safety data. After 12 months of tofacitinib 5 mg twice daily in OCTAVE Open, 68.3% of patients were in remission, 73.9% had endoscopic improvement, and 77.5% had a clinical response. At month 36, 50.4%, of the patients were in remission, 55.3% had endoscopic improvement, and 56.0% had a clinical response. The safety profile of tofacitinib 5 mg twice daily revealed no new safety risks associated with long-term exposure up to 36 months. Efficacy endpoints were maintained for up to 36 months, regardless of prior tofacitinib dose, including patients who reduced from tofacitinib 10 mg to 5 mg twice daily upon OCTAVE Open entry. No new safety risks were identified. ClinicalTrials.gov: OCTAVE Sustain (NCT01458574); OCTAVE Open (NCT01470612).

Abstract 2040: Virtual patient simulation improves first-line treatment selection in advanced EGFR-mutated NSCLC

Abstract Background: Patients with advanced EGFR-mutated NSCLC benefit from treatment with EGFR TKIs. However, gaps in oncologists' performance hamper their ability to integrate individualized treatments into the care of patients with this disease. This study was conducted to determine if an online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention improved performance of oncologists in using appropriate strategies to diagnose and manage patients with advanced EGFR-mutated NSCLC. Methods: The CME intervention consisted of two cases presented in a VPS platform that allowed learners to order lab tests, diagnoses and treatments in a manner matching the scope and depth of actual practice. Clinical decisions made by the learners using open field entries within an EHR interface were analyzed and, after each decision, tailored clinical guidance (CG) was provided based on current evidence and expert recommendation. Learner decisions were collected post-CG and compared with each user's baseline (pre-CG) data using a 2-tailed paired T-test to determine P values. The activity posted May 29, 2019; data were collected through October 15, 2019. Results: Significant improvements (reported as absolute) were observed after CG in clinical decisions made by oncologists: Clinical Decision% Absolute Improvement (% correct pre-CG vs % correct post-CG); P valueCase 1 (N=178) 59 YO African American female recently diagnosed with lung cancer after 6-week history of fatigue, cough, dyspnea; nonsmoker with history of hypertensionCase 2 (N=93) 51 YO male recently diagnosed with stage IV lung cancer with liver metastases after presenting with hacking cough, fatigue, and weight loss for the past 3 months; 10 pack-year history of smoking and hypertensionOrder PD-L1 expression14% (69% vs 83%); P&amp;lt;.0015% (79% vs 84%); P=.02Order brain MRI with/without contrast21% (53% vs 74%); P&amp;lt;.00111% (67% vs 78%); P=.001Order EGFR mutation test via tumor biopsy6% (84% vs 90%); P&amp;lt;.0015% (85% vs 90%); P=.02Diagnose stage IV, NSCLC, adenocarcinoma, EGFR del19 with multiple brain metastases37% (26% vs 63%); P&amp;lt;.001–Diagnose stage IVB, NSCLC, adenocarcinoma, EGFR del19–29% (41% vs 70%); P&amp;lt;.001Start first-line EGFR TKI41% (45% vs 86%); P&amp;lt;.00129% (54% vs 83%); P&amp;lt;.001Selection of osimertinib as first-line treatment26% (37% vs 63%); P&amp;lt;.00123% (49% vs 72%); P&amp;lt;.001 Conclusions: This study demonstrated that VPS that immerses and engages oncologists in an authentic and practical learning experience can significantly improve evidence-based clinical decisions related to diagnosis and management of patients with advanced EGFR-mutated NSCLC. Continued educational activities are needed to address the residual gaps in appropriate treatment and increase oncologists' confidence in this clinical setting. Citation Format: Michelle A. Worst, Rich Caracio, Donna L. Topping, Suresh S. Ramalingam. Virtual patient simulation improves first-line treatment selection in advanced EGFR-mutated NSCLC [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2040.

Clinical Perspective Concerning Abdominal Entry Techniques

Entry into the abdomen during operative laparoscopy is a source of some controversy regarding the safest and most useful method. The objective of this review is to describe, compare, and contrast the most popular entry techniques. Data were collected from the historical starting point until present day from English language journal articles and book chapters. Descriptive accounts dating back to the start of laparoscopy in the 1970s and spanning to present day well-designed randomized controlled trials and Cochrane reviews were compiled to evaluate the evidence for the effectiveness and safety of abdominal entry techniques. The most common sites of entry are the umbilicus and the left upper quadrant. Between the Veress needle, direct trocar insertion, and open entry there is no high-quality evidence to suggest that any of these offers a universal safety advantage. The Veress needle is still the most used among gynecologists and facilitates primary trocar placement. Direct trocar entry under laparoscopic visualization may be underused, is faster, and may result in fewer failed entries. Open (Hasson) entry can be more technically challenging, but may be best for patients with suspected intra-abdominal adhesions. Surgeon comfort is critical in choosing the entry site, method, and equipment. Surgeon familiarity with entry-failure troubleshooting, possible complications, and management is essential because major entry complications are rare in modern laparoscopy but critical because the essential steps of recognition and management can be lifesaving.