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Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study
Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo
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Gaia, M.C. Sighinolfi, B. Rocco, M. Cannoletta, V. Sampogna, A. Lamarca, C. Alboni" "autores" => array:7 [ 0 => array:3 [ "nombre" => "G." "apellidos" => "Gaia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "M.C." "apellidos" => "Sighinolfi" "email" => array:1 [ 0 => "mariachiara.sighinolfi@asst-santipaolocarlo.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "Rocco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Cannoletta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "V." "apellidos" => "Sampogna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Lamarca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "C." "apellidos" => "Alboni" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Obstetricia y Ginecología, ASST Santi Paolo e Carlo, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Urología, ASST Santi Paolo e Carlo, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Obstetricia y Ginecología, Universidad de Módena y Reggio Emilia, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laparoscopic and robot-assisted surgery are widely employed in gynecological, urological and gastrointestinal surgery<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>; the creation of a pneumoperitoneum is the first step of all minimally invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The placement of the initial trocar is an essential part, in which injuries to the bowel or major vessels should be firmly avoided.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> The step could be more demanding in bariatric surgery, as well patients who underwent previous surgery, according to the recent survey from Shababi et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There are several ways to obtain the first access, either open and closed. The open approach is performed via a mini-laparotomy: despite quite safe, the technique can be time consuming and impaired by an inadequate length of skin incision resulting in air leakage. Even if considered safe, visceral complications are reported in the literature as well.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The closed Veress needle technique is widely accepted because of the fast achievement of the pneumoperitoneum that facilitates port placement. However, iatrogenic injuries have been reported as well, especially in patients with previous surgery and several reports demonstrate that the use of Veress needle entry is associated with a significantly higher incidence of extraperitoneal insufflation compared with other techniqueas direct trocar entry. Overall, Veress needle has significantly higher incidences of complications, including failed entry, omental injury, and insertion site infection.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9–11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The optical trocar access (OTA) may overcome the concerns associated with both the Veress needle and open techniques. The OTA consists of a modified closed technique in which the path of the initial trocar is viewed directly with a laparoscope during the insertion. The real-time visualization of each abdominal layer minimizes the risk of vascular or bowel injuries; moreover, the diameter of the opening corresponds to the diameter of the trocar with OTA, with the potential avoidance of gas leakage.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The advantages of OTA are particularly evident in difficult cases, such as severely obesity patients and in those who had previous abdominal surgery.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,8</span></a> Furthermore, it facilitates a safe trocar insertion in the umbilical and peri-umbilical region, where the preperitoneal fat and the omentum can be scarcely distinguishable and the round ligament of the liver may also be an issue<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>; moreover, the midline insertion is more prone to vascular injury.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A learning curve (LC) effect for OTA has been invoked in previous studies - even if barely analyzed. The insertion time of the optical trocar is supposed to be affected by the LC<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>; in the paper by Tanaka et al., a number of 30 OTA was mentioned as a possible threshold to define expertise in the procedure.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We aim to evaluate the impact of the learning curve within the first thirty cases of OTA performed by a trainee, by analyzing the effectiveness (insertion time) and safety of the procedure together with the corrections required by a senior surgeon for a successful access. To this purpose, we designed a randomized prospective study comparing the outcomes of OTA achieved by a trainee to those achieved by an expert surgeon on a series of 60 gynecological consecutive laparoscopic procedure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This is a prospective randomized study conducted from March to November 2021 at the Department of Obstetrics and Gynecology, Medical University of Modena and Reggio Emilia, in collaboration with the Department of Obstetrics and Gynecology Hospital of Sassuolo, Italy. The study was approved by the local Ethics Committee of the Medical University of Modena and Reggio Emilia. Patients gave informed written consent, and all procedures were carried out in accordance with the ‘Good Scientific Practice Standards’ set forth by the Medical University of Modena, which are based on the ethical standards of the revised Helsinki Declaration of 2008.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0035" class="elsevierStylePara elsevierViewall">A pre-planned number of 60 female patients were consecutively enrolled and randomized to have the first OTA insertion by a junior or an expert surgeon. The study included patients elected to laparoscopic gynecological surgery for either benign and oncological diseases. Inclusion criteria were age between 18 and 60 years, BMI between 19 and 34.9. Exclusion criteria were presence of hemoperitoneum, ascites or peritoneal surface oncological infiltration evaluated at RMN or TAC.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patient is placed in a supine position, strictly flat of the surgical bed not to change the expected distance between the umbilicus and the bifurcation of iliac vessels as happens with Trendelenburg position. All the patients received standard curarization and general anesthesia with endotracheal intubation, a nasogastric tube and a Foley catheter insertion. The initial entry site was a 10-mm to 11-mm skin incision made just in the fundus of the umbilicus, aimed to the medial side of the anterior rectus sheath. It is not necessary to dissect and open the fascia. The trocar is inserted into the abdomen under constant direct visualization using a 10-mm 0° laparoscope, which is assembled within the trocar. The trocar is moved through the subcutaneous fat with a twisting motion while at the same time the abdominal wall is retracted with the help of the assistant in order to maintain an angle of 90 degree with the tip of the trocar, and a steady and gentle pressure is applied downward. This is done until the anterior rectus sheath is reached and identified; the applied pressure to the trocar is then released. The trocar is then moved with the same motion to traverse the next layer, the rectus abdominis muscle and the pressure is applied and released again. This procedure is repeated for all the other layers: the posterior rectus sheath, the preperitoneal fat, and the peritoneum until the peritoneal cavity is reached. At this point, the 0° laparoscope and the tip-dissecting of the trocar are removed, and the low-flow CO2 insufflation is started. The 0° laparoscope without the obturator is reinserted to check the proper position of the trocar cannula. If the tip of the trocar cannula is found to be partially in the preperitoneal space, the insufflation is stopped; the 0° laparoscope is removed, reinserted in the obturator, and carefully advanced further using the same principles described above.</p><p id="par0045" class="elsevierStylePara elsevierViewall">An educational video is provided in the Supplementary Section.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Learning curve assessment</span><p id="par0050" class="elsevierStylePara elsevierViewall">After a random allocation (Graphpad.com), the performance of 30 cases of OTA from a single junior surgeon were compared to those of 30 cases performed by a single senior surgeon. Past surgical experience of the trainee consisted of approximately 50 laparoscopic cases as assistant. Before participating into the current study, the junior surgeon received a theory training session with a detailed explanation of the principle of the procedure, equipment, handling and anatomy of the abdominal wall before starting the study. The performance of the trainee was supervised by the expert in all cases and corrections are made in case of mistakes; a third surgeon out of the surgical field collected data.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The evaluation of the learning curve is based on following parameters:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1)</span><p id="par0060" class="elsevierStylePara elsevierViewall">insertion time of the first optic trocar: time from skin incision to the visualization of the peritoneal cavity by the direct vision of the camera, once the blunt-dissecting obturator of the trocar has been removed.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2)</span><p id="par0065" class="elsevierStylePara elsevierViewall">the number of corrections by the senior surgeon assisting in order to redirect the orientation of the axis of the trocar in the right position. Each way of correction was considered apart: a) lateral correction: any deviation from the midline corresponding to the linea Alba on the right or left axis; b) longitudinal correction: any deviation from the angle of 90 degree between the line of insertion of the optical trocar and the abdominal wall lifted by manual traction.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3)</span><p id="par0070" class="elsevierStylePara elsevierViewall">the number of times the tip of the trocar stopped in the preperitoneal layer</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4)</span><p id="par0075" class="elsevierStylePara elsevierViewall">mistakes of the skin incision; a) too small incision needing for a further incision and time consuming; b) too large leading to gas loss and exceeding movements of the umbilical trocar</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5)</span><p id="par0080" class="elsevierStylePara elsevierViewall">the number of times the tip of the trocar ends under the omentum (without visceral injuries nor omental bleeding)</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6)</span><p id="par0085" class="elsevierStylePara elsevierViewall">any intraoperative complications (vascular, intestinal, urological), recorded according to the Clavien-Dindo definition</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The latter (5 and 6) were considered major mistakes, whereas the remaining ones (2–4) were considered as minor.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In order to analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1–10; cases 11–20; cases 21–30) for both surgeons (trainee and expert) and variables of the LC were compared.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The primary endpoint is to evaluate insertion times obtained by the trainee stratified into groups (cases 1−10; 11−20; 21−30) and to compare with those from an expert surgeon. The number of corrections and minor mistakes along with the learning curve is considered as a secondary endpoint.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0105" class="elsevierStylePara elsevierViewall">A descriptive analysis of the overall cohort of patients is provided. Nominal variables are reported as numbers and frequencies, and continuous variables as mean ± standard deviation. The following statistical tests were applied: <span class="elsevierStyleItalic">t</span>-test for unpaired samples for continuous variables; the chi-squared test or the Fisher's exact test for categorical data, where appropriate. <span class="elsevierStyleItalic">P</span> < .05 was considered statistically significant. The Statistical Package for Social Sciences (SPSS), version 19 (IBM Corp., USA) was used for statistical analyses.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">Overall, mean age of the patients was 46 years (DS 12.4) and mean BMI was 26 (DS 5.9); 24 patients (40%) had a history of previous abdominal surgery. Nineteen (32%) had a diagnosis of uterine myomas, 17 (28%) of endometriosis, 6 (10%) of endometrial cancer, and 18 (30%) patients of ovarian disease.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Considering the whole cohort, mean insertion time for the optical trocar access was 56.5 s (DS 5.9). No major intra-operative or post-operative complications were recorded within the whole series.</p><p id="par0120" class="elsevierStylePara elsevierViewall">As far as the learning curve is concerned, mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 ± 57 s vs 33 ± 11 s respectively, <span class="elsevierStyleItalic">P</span> = .01). For cases 11−20 and 21−30, time advantage of the senior surgeon is less evident (<span class="elsevierStyleItalic">P</span> = .05), as reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The number of corrections and mistakes in skin incision is reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, stratified into steps of the learning curve. The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups (5/30 for trainee vs 1/30 for expert, <span class="elsevierStyleItalic">P</span> = .09), as well as the number of times the tip of the trocar ends under the omentum (1/30 for the trainee vs 0/30 for the expert, <span class="elsevierStyleItalic">P</span> = .5). No intraoperative major complications occurred in both groups nor insertion site infection in the immediate postoperative time. Patients were reasddressed 6 months after surgery and no trocar site hernia was reported in neither group.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The optical trocar access is an accepted and well coded technique to effectively access the peritoneal cavity. Its use has been described for gastrointestinal surgery and gynecological interventions<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11</span></a>; more recently, case series dealing with OTA adapted for robotic surgery has been reported as well.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,13</span></a> Moreover, novel devices for optical trocar access - such as the Kii Fios First entry trocar (Applied) - have been studied, in order to further optimize the time for the first trocar insertion.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Despite all the data from the literature, in this almost–blind procedure of the abdominal cavity entry the surgeon direct experience is most likely the most influential deciding factor. Coming from open or Verress technique OTA impact the unexperienced surgeon as a highly demanding procedure in terms of psychomotor skill and eye coordination.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The surgeon’s limited experience is the main variable seemingly affecting a successful and fast insertion of the optical trocar.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Tanaka et al. performed a propensity score matching analysis that compared OTA to open access on 384 patients.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Beyond the evaluation of time for surgical insertion, authors analyzed factors possibly affecting a successful result, including patient’s age, sex, BMI, comorbidities, history of abdominal surgery, oncologic indication and surgeon’s expertise. At the multivariable analysis, a limited surgical experience with the trocar optical access, ie <30 cases, was the only variable associated with prolonged time (OR = 3.45, 95%CI 1,49−8,33), whereas BMI and previous history of abdominal surgery were not.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">We intentionally analyzed the learning curve within the very first 30 cases performed by a surgeon naïve to the OTA, compared to findings by an expert surgeon. Unexpectedly, we found that after only 10 cases the insertion times from the trainee did not differ significantly from those from the expert, suggesting a faster learning curve than the one reported by Tanaka.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Moreover, the times we described – ranging from a minimum of 33 s for the expert to a maximum of 91 s for trainee’s initial cases - were consistent with those from other studies on optical trocars: Lombezzi et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> McHernan et al.,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> String et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Hallfeld et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> reported a mean time of 55 s, 60 s, 94 s and less than 4 min, respectively. Berch et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> recorded a mean of 28 ± 12 s for the insertion of the optical trocar, but it should be remarked that time assessment from their series were only partial. Thus, the time for optical trocar insertion in the current series turned out to be acceptable since the very initial phases of the learning curve.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Beyond the length of the OTA step, we addressed the number corrections for a proper insertion and correction of mistakes in skin incision. Longitudinal correction of movement and too large skin incision were the only minor mistakes we found, that promptly improved after the first 10 cases. Noticeably, there was no difference in major mistakes between expert and novice surgeons; no any-grade complication was recorded within the current series.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Previous Authors suggested that surgical education may be useful for the development of surgeons’ skills with regard to the OTA, with virtual systems for training being proposed as well.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Surely, the optical trocar insertion requires coordination of twisting movement, dosage of pression, eye discrimination of the abdominal layers. The key technical points for a proper placement are: - proper lift of the skin with grasping by forceps or hands lateral to skin incision; - adequate skin incision; - vertical trocar insertion, to avoid inappropriate angles; - excellent visualization, with avoidance of a forced insertion until optimal vision of all layers; - coordination of vertical force, rotational torque together with the knowledge of tissue consistence.</p><p id="par0160" class="elsevierStylePara elsevierViewall">From the current case, some consideration may arise.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The constant presence of the senior surgeon guided the experience of the junior in the live interaction with the anatomy, the instant correction played a main role in the haptic feedback of the damping and friction in contact with different layers of the abdominal wall. This dedicated technical assistance may have played a main role in the fast acquisition of short time and safe technique for optical trocar insertion since the very initial phases of the learning curve.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Longitudinal corrections were more frequent than lateral ones. This data may be related to the prudent tendency to avoid 90 degree of introduction to the abdominal wall. This exposed to longer and longitudinal path of the trocar into the abdominal wall in the preperitoneal area creating a wrong fulcrum provoking postoperative pain due to over stress of the lever of the camera. This mistake was progressively reduced over the cases with growing of the skill of the operator.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The study took place over a quite long period of time due to concomitant spread of the Covid SARS infection that decelerate the access of non oncological cases to the OR. This dilution may have provoked a loss of continuity in the learning curve.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The current study is not devoid of limitation. First, the evaluation of a single trainee may affect the reproducibility of the learning curve as performed by other trainees; nevertheless, it should be reminded that insertion times from either the trainee and the expert are fast and similar to those previously reported in the literature, as aforementioned. Second, the series involves only procedures from the gynecologic surgery; however, it could be assumed that OTA technique and LC are seemingly transferrable to other kind of intervention and site of insertion. Third, the study lacks of evaluation of OTA in the context of robotic surgery.</p><p id="par0185" class="elsevierStylePara elsevierViewall">The use of the robotic scope, which is different in size and weight from the laparoscopic one, could affect OTA technique and the learning curve. Further studies - involving robotic procedures and including multiple surgical indications - are planned to extend the use of OTA across surgical fields.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0190" class="elsevierStylePara elsevierViewall">The optical trocar access is a fast and simple way to achieve the pneumoperitoneum and the first trocar insertion as a single-step. The current series confirms the effectiveness of the technique since the very beginning of the learning curve, whereas the direct visualization of layers allows a safe insertion with little or no-need for corrections.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2084006" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1777564" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2084005" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1777563" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Learning curve assessment" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-06" "fechaAceptado" => "2023-05-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1777564" "palabras" => array:5 [ 0 => "Optical trocar access" 1 => "Laparoscopy" 2 => "Learning curve" 3 => "Insertion time" 4 => "Complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1777563" "palabras" => array:5 [ 0 => "Acceso con trocar óptico" 1 => "Laparoscopia" 2 => "Curva de aprendizaje" 3 => "Tiempo de inserción" 4 => "Complicaciones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1−10; 11−20; 21−30) for both trainee and expert and LC variables were compared.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, <span class="elsevierStyleItalic">P</span> = .01). For cases 11−20 and 21−30, time advantage of the senior surgeon is less evident (<span class="elsevierStyleItalic">P</span> = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El acceso con trocar óptico (ATO) es una técnica modificada de laparoscopia cerrada cuyo objetivo es minimizar el riesgo de lesiones vasculares o intestinales y reducir la posible fuga de gas. Se ha analizado el efecto de la curva de aprendizaje (CA) para el ATO, considerando n = 30 procedimientos como umbral para definir un nivel aceptable de experticia. Nuestro objetivo es evaluar el impacto de la CA en los primeros treinta casos de ATO realizados por un aprendiz.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio prospectivo aleatorizado en 60 pacientes planificadas para cirugía ginecológica laparoscópica. Las pacientes fueron seleccionadas aleatoriamente para el ATO realizado por un cirujano sin entrenamiento previo en la técnica o por un cirujano experto. La CA se evaluó mediante: 1) tiempo hasta lograr el acceso; 2) número de correcciones hechas por el experto; 3) número de veces en que la punta del trocar se detuvo en la capa preperitoneal; 4) errores al realizar la incisión en la piel; 5) veces en que la punta del trocar termina bajo el epiplón; 6) complicaciones. Para analizar el CA en los 30 primeros casos, se estratificaron los procedimientos en 3 grupos (casos 1−10; 11−20; 21−30) tanto para el aprendiz como para el experto y se compararon las variables de la CA.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">De forma global, el tiempo medio de inserción para el ATO fue de 56 segundos. No se registraron complicaciones intraoperatorias ni postoperatorias graves. El tiempo medio de inserción fue estadísticamente más largo para el aprendiz en comparación con el experto en los 10 primeros casos (91 s frente a 33 s respectivamente, <span class="elsevierStyleItalic">P</span> =,01). En los casos 11−20 y 21−30, la ventaja de tiempo del cirujano experto se hizo menos evidente (<span class="elsevierStyleItalic">P</span> =,05). El número de veces que la punta del trocar se detuvo en la capa preperitoneal fue similar entre los grupos, así como las veces que la punta del trocar llegó por debajo del epiplón.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La técnica de ATO es rápida y reproducible para realizar el neumoperitoneo y la inserción del primer trocar en un solo paso. La serie actual confirma la eficacia de la técnica desde el inicio de la CA.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Junior surgeon \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expert surgeon \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insertion Time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sec \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">sec \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 1−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91 (58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 11−20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 21−30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68 (26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Longitudinal corrections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 1−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 11−20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 21−30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lateral corrections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 1−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 11−20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 21−30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exceeding length of skin incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 1−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 11−20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 21−30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inadequate length of skin incision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n/n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 1−10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 11−20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases 21−30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3451097.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Insertion times, the frequency of corrections and of mistakes in skin incision stratified into steps of the learning curve (cases 1–10; 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