Natural Orifice Endoscopic Transgastric Distal Pancreatectomy, A Prospective Randomized Controlled Trial. Natural orifice surgery may represent a paradigm shift in the area of minimally invasive surgery and therapeutic endoscopy. However, studies to date have been limited primarily to small ca...se series with small sample sizes. There has been no large rigorous randomized controlled trial of natural orifice surgery to date. Early work on procedures such as peritoneoscopy, oophorectomy and tubal ligation, while pioneering, have reproduced laparoscopic procedures with minimal morbidity and mortality. In contrast, distal pancreatectomy has a post-operative morbidity of more than 50% even in high volume tertiary care centers. As a highly morbid surgery, the post-operative event rate would allow for a significant difference to be seen in a trial of conventional versus NOTES distal pancreatectomy. We have recently completed a prospective randomized controlled trial of NOTES versus laparoscopic distal pancreatectomy in a swine model which builds on our earlier non-survival work. This video focuses on the endoscopic technique.