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Hevia, J. Lorca, M. Hevia, A. Domínguez, J. López-Plaza, A. Artiles, S. Álvarez, Á. Sánchez, A. Fraile, L. López-Fando, E. Sanz, M. Ruiz, E. Alcaraz, F.J. Burgos" "autores" => array:14 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Hevia" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Lorca" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Hevia" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Domínguez" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "López-Plaza" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Artiles" ] 6 => array:2 [ "nombre" => "S." "apellidos" => "Álvarez" ] 7 => array:2 [ "nombre" => "Á." "apellidos" => "Sánchez" ] 8 => array:2 [ "nombre" => "A." "apellidos" => "Fraile" ] 9 => array:2 [ "nombre" => "L." "apellidos" => "López-Fando" ] 10 => array:2 [ "nombre" => "E." "apellidos" => "Sanz" ] 11 => array:2 [ "nombre" => "M." "apellidos" => "Ruiz" ] 12 => array:2 [ "nombre" => "E." "apellidos" => "Alcaraz" ] 13 => array:2 [ "nombre" => "F.J." 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New training model for vascular lesions" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "447" "paginaFinal" => "449" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Aguilera, J. Gómez Rivas, M. Álvarez-Maestro, L. Martinez Piñeiro" "autores" => array:4 [ 0 => array:3 [ "nombre" => "A." "apellidos" => "Aguilera" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "J." "apellidos" => "Gómez Rivas" "email" => array:1 [ 0 => "juangomezr@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Álvarez-Maestro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Martinez Piñeiro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario la Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación, Hospital Universitario la Paz (IdiPAZ), Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Cómo enfrentarse a complicaciones complejas durante cirugía laparoscópica? Nuevo modelo de aprendizaje en lesiones vasculares" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 642 "Ancho" => 1800 "Tamanyo" => 232350 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Dissection of the vena cava, right renal hilum. B) Cavotomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the worst situations that we can face during laparoscopic surgery, whether due to oncological or benign pathology, is accidental vascular injury. In the urologic setting, it is more frequent during retroperitoneal surgery, due to the presence of the great vessels, with their multiple branches and normal variations. However, other surgical fields, such as the pelvis or those related to other specialties (pulmonary, among others), are not exempt from this possibility.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The cause of these injuries can be considered to be multifactorial. On the one hand, we find causes that depend on the surgical team, inherent to the surgeon and assistant or those related to each case: large tumor masses, surgical history, radiotherapy, etc. Surgical disorientation is usually the origin of the vascular injury and may be related to the greater or lesser experience of the operator, the surgical technique chosen due to the lack of anatomical references, or the complexity of the case.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Human error is inevitable. Although we cannot eliminate this error, we can design training systems to mitigate its frequency and consequences, just as aviation pilots do during their training. Different challenges have arisen with the development of minimally invasive techniques, largely associated with longer learning curves; we must understand that achieving part of this curve does not require patients for skill acquisition, these can be learned in training models.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On this basis, we have developed an animal training model in serious complications, such as vascular injuries in urological surgery.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Model</span><p id="par0025" class="elsevierStylePara elsevierViewall">This model has the approval of the Experimental Surgery Service of our institution, as required by the European Directives for the protection of animals used for scientific and experimental purposes (86/609/EEC). Urologists with previous experience in laparoscopic surgery are selected for this model.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Positioning</span><p id="par0030" class="elsevierStylePara elsevierViewall">The chosen experimental animal is a 30−40 kg pig. The animal is placed in the supine position with the Trendelenburg position. We proceed to create the pneumoperitoneum by inserting a Veress needle at the level of the umbilicus. The procedure is performed with intra-abdominal pressure of 12−13 mmHg. Subsequently, the trocars are inserted. In this first phase, we initially placed four trocars (two of 10 mm, one for the camera and one for the surgeon's right hand and two 5 mm trocars for the left hand and assistant) arranged in a similar way as for radical prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Vascular injuries</span><p id="par0035" class="elsevierStylePara elsevierViewall">During the first exercise, we dissected the iliac vessels and then caused an electrosurgical sharp injury in the iliac vein with the laparoscopic hook. The vascular suture is performed with a 5/0 synthetic, non-absorbable (polypropylene) surgical suture cut at approximately 15 cm.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The next injury is performed longitudinally to the vessel and iliac vein; this time of approximately 3−4 mm long. Using the same type of suture previously described, a continuous suture is performed. Once the bleeding was controlled, we made an injury to the contralateral iliac vein, but this time without previously dissecting it. We repeat the two types of injuries one more time (sharp and 3−4 mm longitudinal).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Next, we change the position of the animal to left lateral decubitus. With the insertion of 4 trocars, we dissected the vena cava above and below the right renal hilum, placing one tourniquet in each case. Likewise, we also dissected the left renal vein and it was referenced with another tourniquet. After clipping the right renal artery, we placed the tourniquets (first in the left renal vein, then caudal to the right renal hilum and finally cranial to the hilum). We performed a cavotomy with the right renal vein included as well, to exemplify the surgical technique for renal tumors with level I-II tumor thrombus. We performed the cavotomy closure with a continuous, non-absorbable (polypropylene) surgical suture of approximately 20 cm. Once finished, we released the tourniquets (cranial to renal hilum first) and hemostasis check (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In the following exercise, we changed the animal's position to lateral decubitus and made the two previously described injuries at the iliac vein (sharp and 3−4 mm), but this time on the anterior aspect of the vena cava. Once the injuries were resolved, we generated sharp injuries on the posterior side of the vena cava, which make us mobilize it and work in coordination with the assistant.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally, we use the undissected section of the vena cava to cause an injury to the anterior face, but this time without dissecting all the fat tissue in front of it. This exercise seems more realistic, since the injury is produced without having the surface of the vein unprepared, which requires initial control of the injury with a clamp and then dissection of the tissue around the clamp, until the injury is clearly exposed, and repair is carried out.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Arterial injuries are reserved for the last minute, since the longest duration of the animal is guaranteed. The injury caused is sharp, at the level of the iliac arteries, the suture was performed with synthetic surgical suture, non-absorbable (polypropylene) 4/0 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Laparoscopic control of a vascular injury is a situation that requires the maximum preparation of the surgical team involved, regardless of the specialty. It requires not only the greatest skills in laparoscopic suturing, but also good coordination between the surgeon and his assistant. In recent years, we have witnessed the appearance of multiple laparoscopic suture learning systems or models, mainly aimed at vesicourethral anastomoses.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> These models have demonstrated the possibility and utility of training situations that we will face in certain urological surgeries. This is why we believe that facing a situation of vascular injury in the context of an experimental operating room, we can develop a series of maneuvers which may help us control this injury. The coordinated teamwork is essential to deal with vascular injury caused laparoscopically. The speed of reaction and manual dexterity seem to us of great importance. The model used is adequately adjusted to our needs, with similar vessel diameter and anesthetic management to those of our concern.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In addition to surgical dexterity, there is another aspect to consider which is the development of non-technical skills. These are represented by cognitive and interpersonal skills that complement practical and technical skills, such as decision-making, leadership, and teamwork. In surgical specialties, these behavioral or non-technical aspects of performance (e.g., communication failure), rather than lack of technical expertise, are often the underlying causes of adverse events. Traditionally, these aspects of surgical performance have been largely informally developed rather than explicitly addressed in training.</p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Model" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Positioning" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Vascular injuries" ] ] ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Aguilera A, Gómez Rivas J, Álvarez-Maestro M, Martinez Piñeiro L. ¿Cómo enfrentarse a complicaciones complejas durante cirugía laparoscópica? Nuevo modelo de aprendizaje en lesiones vasculares. Actas Urol Esp. 2020;44:447–449.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 642 "Ancho" => 1800 "Tamanyo" => 232350 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Dissection of the vena cava, right renal hilum. B) Cavotomy.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 563 "Ancho" => 900 "Tamanyo" => 75995 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Iliac vascular injury.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development and validation of a training and assessment tool for laparoscopic radical nephrectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. 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