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Trocar shortening for pediatric vitreoretinal surgery with a 3D printed trocar spacer: Report of two cases
Espaciador de trocares para cirugía vitreorretiniana pediátrica utilizando una impresora 3D: reporte de 2 casos
A. Di-Lucianoa, R. Gómez-Nuñezb, F. Acostac, L. Rivas-Vegad, V. Morales-Cantóna, M. Trujillo-Alvareza, L. Cernichiaro-Espinosaa,
Corresponding author
a Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, IAP, Mexico City, Mexico
b Biomedical engineer, private practice, Mexico City, Mexico
c CEO, Custom Surgical, Munich, Germany
d Anesthesiology department, Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, IAP, Mexico City, Mexico
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"apellidos" => "Cernichiaro-Espinosa" "email" => array:1 [ 0 => "linda.cernichiaro@retinakids.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, IAP, Mexico City, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Biomedical engineer, private practice, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CEO, Custom Surgical, Munich, Germany" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Anesthesiology department, Pediatric Retina Unit, Retina and Vitreous Department, Asociación para Evitar la Ceguera en México, IAP, Mexico City, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Espaciador de trocares para cirugía vitreorretiniana pediátrica utilizando una impresora 3D: reporte de 2 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1254 "Ancho" => 1258 "Tamanyo" => 165398 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cannula-trocar system 27-gauge.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Nowadays pediatric vitreoretinal(VR) surgeons use different techniques for trocar placement to avoid iatrogenic injury to the lens or the retina. Four main characteristics concern trocar placement: ciliary body length (CBL), axial length (AL), lens thickness (LT) and scleral thickness (ST).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The pars plana is not fully formed until approximately the age of 8 or 9 months. Therefore, trocar insertion is performed through the pars plicata when a posterior approach is desired in the newborn eye.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The CBL has been used as a reference point to decide the location of the sclerotomies and it enlarges depending on the age and the measured quadrant from 3.06 mm to 4.94 mm.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–8</span></a> Thinner instruments along with nomograms with scleral transillumination for trocar placement are helpful to avoid iatrogenic injury to the retina when posteriorly placed.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The current available trocar systems diameters are: 20-gauge (ga): 0.91 mm; 23-ga: 0.64 mm; 25-ga: 0.50 mm; and 27-ga: 0.40 mm.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The mean AL and LT are at 1–6 months: 19.54 mm and 3.90 mm; 7–12 months: 20.43 mm and 3.87; 13–24 months: 20.43 and 4.06; 25–36 months: 21.63 mm and 4.11; and over 48 months: 21.80 mm and 3.9 mm respectively. There is an increase in sclera thickness from 0.45 mm in neonates to 1.09 mm in adults.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> As these measurements are not a rule of thumb and are under constant change, shorter instruments represent a safer method for VR surgery. The length of each system may vary according to manufacturing company. The approximate length ranges between 8−10 mm.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently, short trocar systems have been developed: non-valved 25-ga short with a 0.5 mm diameter and 6 mm of length (Alcon Laboratories Inc, Forth Worth, Texas, USA) and valved 27-ga ultra-short with 0.4 mm diameter and 25% reduced length (Dutch Ophthalmic Research Center (DORC), International, The Netherlands ).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Despite these advancements on shorter instrumentation, its availability is limited in some countries. Therefore, we designed a 3D printed spacer device that shortens the length of the trocar maximizing the stability of the trocar-cannula system whilst minimizing risks in small eyes that has proven to be effective and reproducible in our practice.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Trocars</span><p id="par0025" class="elsevierStylePara elsevierViewall">We used standard 27-ga and 25-ga trocars and cannulas included in surgical VR packs of EVA system (DORC, International, The Netherlands).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Spacer</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 1.5 mm × 3 mm prototype spacers were created with a Prusa MK3 3D printer (0.4 mm nozzle) with Fuse deposition melting (FDM) technology. The pieces were printed with a layer height of 50 microns in Polylactic acid or polylactide (PLA) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Spacer placement</span><p id="par0035" class="elsevierStylePara elsevierViewall">The spacer can be placed in two places: between the blade’s base and the trocar, and between the trocar and the sclera depending on the desired amount of shortening (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical cases</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Case 1</span><p id="par0040" class="elsevierStylePara elsevierViewall">A female premature infant of 32 weeks of gestational age and 1000 grs of birth weight was referred to us after evaluation by an ophthalmologist with a retinal detachment due to retinopathy of prematurity stage 4b. 24 h prior to surgery, intravitreal ranibizumab 1.25 mg (0.025 ml) was injected as important vascular activity was seen. Under general anesthesia the sclerotomies were done 1 mm posterior to the limbus after confirmation with scleral transillumination of the entry site. A 27 ga. trocar with the spacer device in both sides of the trocar was used for this purpose. Vectors to the lens and anterior retina were removed with vitrectomy. Sclerotomies were sutured as routinely in pediatric eyes due to scleral elasticity with vicryl 7−0. No surgical complications were seen.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Case 2</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 5-year-old male patient diagnosed with rhegmatogenous retinal detachment associated with MPPC syndrome (microcornea, posterior megalolenticouns, persistent fetal vasculature and coloboma) and history of blunt trauma. A scleral 240 buckle was performed with special attention to the sutures in the colobomatous area. Sclerotomies were done 1 mm posterior to the limbus after confirmation with scleral transillumination of the entry site. A 25 ga valved trocar with the spacer device placed on both sides of the trocar was used. As the space for performing surgery was limited due to the very small cornea and eye, the spacer between the trocar and the sclera was removed. Due to the size of the lens (megalolenticonus) and the presence of elongation of the ciliary processes, a lensectomy was performed. Perfluoro n-octane liquid (PFO) was used to reattach the retina and laser was applied in the margin between the retina and the coloboma. 1000 cst silicone oil was left as tamponade. Sclerotomies were sutured with vicryl 7−0. No complications were seen.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Nowadays it remains a challenge to plan a vitrectomy in children due to dynamic anatomical changes. Most of the studies have been based on the location of the sclerotomies but little has been published on the length of the blade when introducing the trocars and their possible complications.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> The currently used spacers are limited and there are few reports in the literature. Babu et al. used a trimmed 42-silicone band as a spacer to shorten regular 25-ga cannulas.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Its drawback is that the perforation of the band can enlarge during surgery causing instability or inadvertent damage to the eyeball.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Ian et al. used shortened regular 25-ga cannulas with 270-silicone Watzke sleeves. These two methods are more time-consuming intraoperatively in comparison with this spacer device, which is produced before the surgical procedure.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This device is easy to manufacture at a low cost and in our experience, proved to be easy to adapt and use in a clinical scenario without complications. In addition, it has a low learning curve because is a simple and intuitive design.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the prototype was developed using printers with PMD technology, the next step would be to use SLA (Stereolitography) technology printers. This type of printing is done on a resin bed which undergoes a UV light curing process. It is much more accurate and therefore can give better results. In addition, some of the SLA materials have been developed for surgical procedures, especially in the dental field. Generally the printing beds of the FMD printers are generally around 20 cm × 20 cm, however, the printing has limits of tolerance that we were challenging when we tried to print those first prototypes. Details of less than 0.5 mm are very difficult to achieve with this technology. SLA printers are generally slightly more expensive (1000–1500 USD), but have a lower print volume, however they are much more precise (visible results from 0.2 mm), making them ideal for this project in the future.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is important to mention that the 3D-spacer placement will be modifiable according to the anatomy of the surgical eye as evidenced in case 2 where the spacer had to be removed. It was removed as it was not facilitating free maneuvers in such a small cornea and eye that would have happened with any other type of spacer. We are aware that the use of a spacer is not a definite substitute for manufactured short trocars that will hopefully eventually be available. Until then, we must rely on the easiest and simplest way to shorten a trocar in these type of complicated surgical scenarios.</p><p id="par0070" class="elsevierStylePara elsevierViewall">When trying to implement a new device that helps prevent complications during VR surgery in children, it is important to take into account its reproducibility in different surgical scenarios which we believe is the major benefit of our implemented device.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary, this 3D printed spacer has proved to effectively shorten the introduced trocar into two different small eyes. More studies are needed to validate the efficacy and safety of this spacer in clinical practice.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1751655" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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" => "xpalclavsec1542806" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1751656" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 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" => "xpalclavsec1542807" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Trocars" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Spacer" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Spacer placement" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Clinical cases" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Case 2" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-02" "fechaAceptado" => "2021-05-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1542806" "palabras" => array:4 [ 0 => "Vitroretinal surgery" 1 => "Pediatric" 2 => "3D printer" 3 => "Trocar spacer" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1542807" "palabras" => array:4 [ 0 => "Cirugía vitreorretiniana" 1 => "Pediatría" 2 => "Impresora 3D" 3 => "Espaciador de trocares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To show the results of a trocar spacer for pediatric vitreoretinal surgery with a 3D printed trocar spacer in 2 cases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We used standard 27 gauge (ga) and 25 ga trocars and cannulae, and prototyped 1.5 mm × 3 mm spacers with a Prusa MK3 3D printer (0.4 mm nozzle) with Fuse deposition melting (FDM) technology. Parts were printed with a 50 μm layer height in polylactic acid or polylactide (PLA). The spacer was placed in two places: between the blade’s base and the trocar, and between the trocar and the sclera depending on the desired amount of shortening. This prototype was used in 2 vitrectomy cases in pediatric patients.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We used this trocar spacer in 2 cases with positive results.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This 3D printed spacer has proved to effectively shorten the introduced trocar into two different small eyes. More studies are needed to validate the efficacy and safety of this spacer in clinical practice.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Mostrar los resultados de un espaciador de trocares para cirugía vitreorretiniana pediátrica con un espaciador de trocar impreso en 3D en 2 casos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Utilizamos trócares y cánulas estándar de calibre 27 y calibre 25, y espaciadores de 1.5 mm × 3 mm prototipados con una impresora 3D Prusa MK3 (boquilla de 0,4 mm) con tecnología Fuse deposition melting (FDM). Las piezas se imprimieron con una altura de capa de 50 micrones en ácido poliláctico o polilactida (PLA). El espaciador lo colocamos en dos lugares: entre la base de la cuchilla y el trócar, y entre el trócar y la esclerótica según la cantidad de acortamiento deseada. Este prototipo se utilizó en 2 casos de vitrectomía en pacientes pediátricos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Utilizamos este espaciador de trocar en 2 casos con resultado positivo.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Este espaciador impreso en 3D ha demostrado acortar eficazmente el trocar introducido en dos casos de cirugía vitreoretiniana en niños. Serán necesarios más estudios para validar la seguridad y eficacia de este espaciador en la práctica clínica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Di-Luciano A, Gómez-Nuñez R, Acosta F, Rivas-Vega L, Morales-Cantón V, Trujillo-Alvarez M, et al. Espaciador de trocares para cirugía vitreorretiniana pediátrica utilizando una impresora 3D: reporte de 2 casos. Arch Soc Esp Oftalmol. 2022;97:473–476.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1766 "Ancho" => 1258 "Tamanyo" => 83065 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">3D spacer diagram.</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" => 1254 "Ancho" => 1258 "Tamanyo" => 165398 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cannula-trocar system 27-gauge.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 430 "Ancho" => 755 "Tamanyo" => 56950 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Trocar spacer in 27 gauge system in pediatric vitreoretinal surgery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Special considerations for pediatric vitreoretinal surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.Y. 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