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Influence of Previous Experience on the Benefits of Laparoscopic Surgical Training Based on Simulation
Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación
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[ "paginaInicial" => "314" "paginaFinal" => "319" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Enrique Toledo Martínez, Jose Ignacio Martín Parra, Cristina Magadán Álvarez, Antonio López Useros, Roberto Fernández Santiago, Sara Regaño Díez, José Luis Ruiz Gómez, Juan Carlos Rodriguez Sanjuan, Carlos Manuel Palazuelos" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Enrique" "apellidos" => "Toledo Martínez" "email" => array:1 [ 0 => "etoledomartinez@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jose Ignacio" "apellidos" => "Martín Parra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Cristina" "apellidos" => "Magadán Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "López Useros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Roberto" "apellidos" => "Fernández Santiago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Sara" "apellidos" => "Regaño Díez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "José Luis" "apellidos" => "Ruiz Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Juan Carlos" "apellidos" => "Rodriguez Sanjuan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Carlos Manuel" "apellidos" => "Palazuelos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital de Laredo, Laredo, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía, Hospital Comarcal Sierrallana, Torrelavega, Cantabria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0030" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 750 "Ancho" => 1333 "Tamanyo" => 132071 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Surgical training has evolved from the master-apprentice relationship of the 18th century (based on the observation and imitation of surgical techniques) to today's complex training methods using computer simulations and virtual reality. However, a milestone in surgical development was marked by William Stewart Halsted and Franklin P. Mall in Baltimore in 1886, in Baltimore, who began training intestinal sutures in experimental animals.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Previously in 1847, the American Medical Association (AMA) was created in order to increase ethical standards in the field of medicine. Likewise, in the field of training, the first association was created in 1876 to reform medical education: the Association of American Medical Colleges (AAMC). Since then, ethics and medical training have evolved, making high-quality technical training necessary prior to patient treatment.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Presently, after the social and technological evolution of recent generations, education is becoming more experiential in content and methodology<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> to adapt to this new profile, as current learning methods and motivations differ from those of previous generations.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> Given this situation, simulation stands out as an important tool for acquiring surgical skills, while also responding to the growing demand of surgical skills training.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of simulation as a surgical training tool has proven to be more effective in the integration of complex clinical-surgical knowledge and skills compared to traditional methods.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6–9</span></a> It has been validated in both behavioral and decision-making techniques.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this study is to assess the evolution of students participating in an intensive practical course of advanced laparoscopic techniques (intestinal anastomosis) based on simulation. Afterwards, the results will be analyzed according to the training level and the previous clinical experience of the participants to determine the influence of these parameters on skill acquisition and the need for evolution or optimization of training systems.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">An observational study was conducted to analyze the participants taking anastomosis courses held at the Valdecilla virtual hospital (Santander, Cantabria) between March 2015 and November 2017. All General Surgery and Gastroenterology participants were included in the study if they had completed the course and had taken it for the first time.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The format of the courses was intensive, with long training sessions (10<span class="elsevierStyleHsp" style=""></span>h/day) concentrated into a short period of time (5 days). They were held quarterly, with 4–8 participants per course and one instructor for a maximum of 3 students. During the sessions, manual side-to-side intestinal anastomoses were created with porcine ex vivo viscera in a laparoscopic endotrainer. This device is basically a closed box made of tinted methacrylate with silicone inlets along the upper side, through which laparoscopic trocars are inserted along with a fiber optic cable supported by a metallic arm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The anastomosis technique used includes interrupted supporting sutures and continuous double suture with Connell sutures at the vertices (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The teaching methodology involved the following steps: provide participants with literature and videos demonstrating the surgical technique; one previous meeting to introduce participants to the simulation laboratory; discussion of articles and overview of the procedure; critical steps of the technique are then demonstrated by the instructor, including the handling of laparoscopic instruments, constant feedback from the instructor, time and quality control, rigorous reflection at the end of the session (debriefing), and deliberate and repetitive practice.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The variables analyzed were the quality parameters for standardized anastomoses based on a Delphi method<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a>: correct distance between stitches (2.5–3.5<span class="elsevierStyleHsp" style=""></span>mm), suture tension (<1<span class="elsevierStyleHsp" style=""></span>cm of excess thread after cutting and traction), eversion of edges and presence of leakage (air leak testing by manometer).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The technical variables studied were: respect for tissue, suture and knotting technique, time and movement, technique compliance and level of independence. The development of the technique was analyzed with the Objective Structured Assessments of Technical Skills (OSATS), which is a validated tool for basic surgical skills assessment.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> Authors like Reznick have designed an OSATS scale to evaluate intestinal anastomoses in live animals,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> including a task checklist that has been used in our experience, giving a score from 1 to 5.</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the anastomoses performed were analyzed and scored by the same group of instructors, and the results obtained for the first and last anastomoses were compared for each participant.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The results were compared between residents-in-training and specialists. Likewise, for our analysis, a subgroup was created of expert participants who had advanced clinical experience (≥50 anastomosis).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical Analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">The statistical analysis was carried out with the 2016 IBM SPSS Statistics for Windows, version 24.0 (Armonk, NY: IBM Corp).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The Kolmogorov–Smirnov test confirmed normal distribution for the <span class="elsevierStyleItalic">time</span> variable alone, for which a bivariate analysis was done with the Student's <span class="elsevierStyleItalic">t</span> test for paired data to compare anastomosis results at the beginning and end of the course. For the rest of the quantitative variables, the Mann–Whitney test was performed, using the Wilcoxon test for related samples. The categorical variables were analyzed by the Chi-squared and McNemar tests in related samples. In situations in which the expected frequencies were less than 5, Fisher's exact test was used.</p><p id="par0070" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">P</span> value <.05 was considered statistically significant.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Forty-five participants (36 women and 19 men) were analyzed; 22 of the participants were residents and 23 specialists. Their average clinical experience was 70.8 anastomoses performed in open surgery (a mean of 15.6 for residents and 136.5 for specialists) and 1.4 in laparoscopic procedures (0.5 residents vs. 3.1 specialists). Thirteen participants had performed ≥50 anastomoses in their daily practice (both open and laparoscopic surgery), all of whom were considered specialists. An average of 16.2 anastomoses per participant were completed during the course.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The technique time was reduced from 116.8 to 60.6<span class="elsevierStyleHsp" style=""></span>min (48.1%) for the residents and from 103.1 to 58.5<span class="elsevierStyleHsp" style=""></span>min for the specialists (43.2%), with a <span class="elsevierStyleItalic">P</span><.001 in both groups. The lengths of the anastomoses decreased from 49<span class="elsevierStyleHsp" style=""></span>mm (first) to 46<span class="elsevierStyleHsp" style=""></span>mm (last) for residents (<span class="elsevierStyleItalic">P</span>=.090), and 51<span class="elsevierStyleHsp" style=""></span>mm (first) to 46<span class="elsevierStyleHsp" style=""></span>mm (last) for specialists (<span class="elsevierStyleItalic">P</span>=.020) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, with an overall improvement in procedural parameters of 80.5% (67.3% in specialists and 94.8% in residents), with a <span class="elsevierStyleItalic">P</span><.001. In the last anastomoses, there were no significant differences between residents and specialists in terms of respect for tissue (4.1 and 4.2, respectively), procedure development (4.5 vs. 4.5), time in movements (3.7 vs. 4.0), level of independence (4.5 vs. 4.5) and suture and knotting (3.8 vs. 4.1) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the quality of the anastomosis, improvements were achieved in the group of residents: 90% increase in adequate tension (<span class="elsevierStyleItalic">P</span>=.012), 75% reduction in everted edges (<span class="elsevierStyleItalic">P</span>=.004) and 60% in leaks (<span class="elsevierStyleItalic">P</span>=.035) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). In addition, the residents obtained final results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% specialists, <span class="elsevierStyleItalic">P</span>=.5864).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The specialists reduced leakage by 20% (<span class="elsevierStyleItalic">P</span>=.754), eversion by 33.3% (<span class="elsevierStyleItalic">P</span>=.453) and the excessive distance between stitches by 57.1% (<span class="elsevierStyleItalic">P</span>=.344). The subgroup with greater previous experience (≥50 anastomoses) presented similar results, without reaching statistical significance in its improvement in terms of anastomotic quality.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The unquestionable importance of laparoscopy in current surgery today requires a change in the training of specialists and the teaching of this specialty to residents, as it has been gaining in importance in the formative stage.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> The implementation of simulation as a fundamental part of training is a highly valued, widely accepted resource<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">16,17</span></a> with subsequent clinical repercussions.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Since the Zendejas et al. study<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> and a study carried out at our hospital by Ruiz Gómez,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> the utility of simulation seems to have been confirmed, and the need to standardize the teaching methodology has been suggested. Continuing with the basis of this latter study, we have sought to assess the influence of experience on the final results.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the present study, we are able to confirm that intensive training in laparoscopic simulation leads to a significant improvement in terms of technical skill, procedural development and time in all participants, regardless of their educational level or previous experience.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding the quality parameters, only the group of residents presented better final results in all the parameters analyzed.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the group of specialists, the improvement of skills did not correlate with the best technical results, which may be a limitation of the sample size of the study.</p><p id="par0125" class="elsevierStylePara elsevierViewall">When we compared the final overall results of the specialists and the residents, we found no differences, with a score of 20.6 and 21.3 respectively (<span class="elsevierStyleItalic">P</span>=.51).</p><p id="par0130" class="elsevierStylePara elsevierViewall">Simulation in laparoscopy seems to be more effective in new participants, those with less clinical experience and residents.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">20,21</span></a> On one hand, students with a lower level of training would have a greater margin for improvement, while surgeons with greater clinical practice and experience may have acquired more rigid skills and theories, which are difficult to modify with simulation. Therefore, the need for a different methodology should be assessed once the technical training has been completed.</p><p id="par0135" class="elsevierStylePara elsevierViewall">It would also be interesting to identify the characteristics of learning and whether the individual style of the participants (Kolb styles<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>) varies with age or experience. However, neither the Richard group<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> with orthopedists nor the Engels group<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> with general surgeons found significant differences between the learning styles of attending surgeons and residents.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite their demonstrated inferiority to distributed or spaced practice (short sessions with rest periods between them),<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">25,26</span></a> we have demonstrated that these intensive courses (similar to the well-known ATLS, for example) provide novice participants (mostly residents) significant immersion in the skills, allowing them to acquire a final level of proficiency that is equal to that of the experts. As for participants with prior experience in these skills (mostly specialists), the course gives them a dose of reinforced training, which plays an important role in skill retention.</p><p id="par0145" class="elsevierStylePara elsevierViewall">However, the exact amount of reinforcement for each surgical skill has not been studied. What we do know is that the simplest tasks require more reinforcement than more complex procedures.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> More studies on this point are needed, but what seems clear is that the concept of training beyond the objectives should be part of any motor skills curriculum in order to optimize the retention of skills acquired through simulation.<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28,29</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Finally, the limitations of the study include the sample size, variability and possible subjectivity of the evaluations. To avoid this measurement bias, we selected the time period in which the same instructors always participated, so the number of participants could not be increased.</p><p id="par0155" class="elsevierStylePara elsevierViewall">For all these reasons, our experience should be extended to more participants in order to expand the demographic, curricular and individual data to assimilate the information presented. In this way, learning patterns could be found in order to optimize and individualize teaching activities.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interests</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1213632" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1213633" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1129304" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1213634" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1129305" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical Analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-16" "fechaAceptado" => "2018-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1129304" "palabras" => array:6 [ 0 => "Simulation" 1 => "Training" 2 => "Laparoscopy" 3 => "Anastomosis" 4 => "Residents" 5 => "Specialists" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1129305" "palabras" => array:6 [ 0 => "Simulación" 1 => "Entrenamiento" 2 => "Laparoscopia" 3 => "Anastomosis" 4 => "Residentes" 5 => "Especialistas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing skill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyze their results depending on their level and previous experience.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analyzed. Manual side-to-side intestinal anastomoses with porcine ‘ex vivo’ viscera were performed in a laparoscopic endotrainer.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (<span class="elsevierStyleItalic">P</span><.001).</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, <span class="elsevierStyleItalic">P</span>=.59), which presented improvement without statistical significance.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El entrenamiento quirúrgico basado en simulación busca la adquisición de habilidades en los participantes noveles y la capacitación en los expertos. El objetivo de este estudio es valorar la evolución de los alumnos en un curso intensivo de anastomosis laparoscópica y el análisis de sus resultados dependiendo de su nivel y experiencia previa.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se analizaron los alumnos de todos los cursos de anastomosis realizados durante 30 meses en el Hospital virtual Valdecilla (Santander). Se realizaron anastomosis intestinales latero-laterales manuales con vísceras «ex vivo» porcinas en un endotrainer laparoscópico.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se analizaron las diferencias técnicas y de calidad entre la primera y la última anastomosis y se comparó la progresión entre residentes y los facultativos especialistas.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 45 participantes, 22 de ellos residentes y 23 especialistas. Se observó una mejoría estadísticamente significativa del 80,5% en todos los parámetros procedimentales (94,8% residentes vs. 67,3% especialistas). El tiempo se redujo un 48,1% en los residentes y un 43,2% en los especialistas (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En cuanto a calidad, se obtuvieron mejorías significativas en el grupo de residentes: incremento del 90% de tensión adecuada, reducción del 75% de bordes evertidos y 60% de las fugas. Además, obtuvieron resultados comparables a los especialistas (27,3% fuga en última anastomosis vs. 34,8% especialistas, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,59), los cuales presentaron mejoría sin significación estadística.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El grupo de residentes presenta una mejora mayor y significativa en habilidades procedimentales y en calidad de la técnica, alcanzando el nivel de los especialistas tras completar el curso.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Toledo Martínez E, Martín Parra JI, Magadán Álvarez C, López Useros A, Fernández Santiago R, Regaño Díez S, et al. Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación. Cir Esp. 2019;97:314–319.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 639 "Ancho" => 850 "Tamanyo" => 64660 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic endotrainer, optics, light source and laparoscopic instruments.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 626 "Ancho" => 850 "Tamanyo" => 64139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Start of supporting sutures for the manual side-to-side entero-enteric anastomosis with ex vivo porcine viscera in a laparoscopic endotrainer.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1166 "Ancho" => 1569 "Tamanyo" => 85786 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Time transpired for first and last anastomoses performed by residents and specialists.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1463 "Ancho" => 2164 "Tamanyo" => 180235 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Procedural results of the first and last anastomoses of residents and specialists.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1186 "Ancho" => 1560 "Tamanyo" => 104654 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Number of anastomoses with deficient quality parameters in the resident and specialist groups.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \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 " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Residents</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Specialists</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" 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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1st Anastomosis \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Last Anastomosis \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="center" 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><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1st Anastomosis \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="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Last Anastomosis \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="center" 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><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" 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></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">Respect for tissue<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.556 \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">Procedure compliance<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.978 \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">Time and movement<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.187 \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">Level of independence<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.763 \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">Suturing and knotting<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.121 \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">Total \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.548 \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">Time (min) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.938 \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">Time (mm) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.090 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.020 \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="char" 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">Excessive distance (<span class="elsevierStyleItalic">n</span>) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.070 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.344 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.673 \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">Edge eversion (<span class="elsevierStyleItalic">n</span>) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.004 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.453 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.297 \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">Insufficient tension (<span class="elsevierStyleItalic">n</span>) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.012 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.728 \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">Leak (<span class="elsevierStyleItalic">n</span>) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.035 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.754 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.586 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2071683.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 20 | 6 | 26 |
| 2024 September | 16 | 5 | 21 |
| 2024 August | 15 | 3 | 18 |
| 2024 July | 18 | 3 | 21 |
| 2024 June | 17 | 2 | 19 |
| 2024 May | 20 | 4 | 24 |
| 2024 April | 39 | 6 | 45 |
| 2024 March | 121 | 6 | 127 |
| 2024 February | 48 | 2 | 50 |
| 2024 January | 26 | 2 | 28 |
| 2023 December | 33 | 5 | 38 |
| 2023 November | 35 | 5 | 40 |
| 2023 October | 66 | 5 | 71 |
| 2023 September | 38 | 0 | 38 |
| 2023 August | 28 | 2 | 30 |
| 2023 July | 15 | 4 | 19 |
| 2023 June | 34 | 2 | 36 |
| 2023 May | 25 | 4 | 29 |
| 2023 April | 24 | 2 | 26 |
| 2023 March | 38 | 6 | 44 |
| 2023 February | 19 | 3 | 22 |
| 2023 January | 15 | 3 | 18 |
| 2022 December | 27 | 7 | 34 |
| 2022 November | 29 | 16 | 45 |
| 2022 October | 27 | 7 | 34 |
| 2022 September | 25 | 24 | 49 |
| 2022 August | 19 | 8 | 27 |
| 2022 July | 39 | 7 | 46 |
| 2022 June | 28 | 7 | 35 |
| 2022 May | 25 | 6 | 31 |
| 2022 April | 42 | 9 | 51 |
| 2022 March | 46 | 12 | 58 |
| 2022 February | 55 | 5 | 60 |
| 2022 January | 41 | 9 | 50 |
| 2021 December | 25 | 12 | 37 |
| 2021 November | 42 | 16 | 58 |
| 2021 October | 30 | 9 | 39 |
| 2021 September | 15 | 12 | 27 |
| 2021 August | 34 | 12 | 46 |
| 2021 July | 33 | 5 | 38 |
| 2021 June | 34 | 10 | 44 |
| 2021 May | 39 | 11 | 50 |
| 2021 April | 59 | 19 | 78 |
| 2021 March | 60 | 7 | 67 |
| 2021 February | 30 | 16 | 46 |
| 2021 January | 23 | 17 | 40 |
| 2020 December | 22 | 11 | 33 |
| 2020 November | 23 | 11 | 34 |
| 2020 October | 22 | 9 | 31 |
| 2020 September | 31 | 11 | 42 |
| 2020 August | 43 | 12 | 55 |
| 2020 July | 35 | 9 | 44 |
| 2020 June | 19 | 14 | 33 |
| 2020 May | 31 | 13 | 44 |
| 2020 April | 11 | 6 | 17 |
| 2020 March | 27 | 6 | 33 |
| 2020 February | 31 | 3 | 34 |
| 2020 January | 22 | 12 | 34 |
| 2019 December | 32 | 4 | 36 |
| 2019 November | 15 | 4 | 19 |
| 2019 October | 18 | 11 | 29 |
| 2019 September | 8 | 6 | 14 |
| 2019 July | 1 | 0 | 1 |
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