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Original article
Robotic anatomical lung resections: Analysis of the learning curve
Resecciones pulmonares anatómicas por vía robótica: análisis de la curva de aprendizaje
M. Teresa Gómez Hernández
Corresponding author
, Marta Fuentes Gago, Nuria Novoa Valentín, Israel Rodríguez Alvarado, Marcelo F. Jiménez López
Departamento de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; robotic surgery has emerged as a new minimally invasive approach for the treatment of thoracic surgical pathology&#46; Several studies have shown that it is a safe&#44; feasible&#44; and oncologically effective technique&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> capable of obtaining similar postoperative morbidity and mortality results to those achieved with video-assisted thoracoscopy surgery &#40;VATS&#41; when compared with the conventional open approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> In addition&#44; some authors describe additional benefits in terms of better ergonomics&#44; three-dimensional viewing&#44; and optimized maneuverability thanks to the 360&#176; rotation of the instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the first robotic lobectomies were described in 2003&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> the implementation of robotic technology in thoracic surgery is still limited&#46; Recently&#44; however&#44; its use in lung resections has been increasing&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The implementation of new surgical techniques requires the evaluation of the surgeon&#8217;s learning curve&#46; Although initial studies have shown that the learning curve for robotic anatomical lung resections ranges from 14 to 32 procedures&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> these studies have focused their analysis on the evaluation of surgical time and postoperative morbidity&#46; However&#44; since the occurrence of postoperative complications is mainly determined by patient characteristics&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> we consider that this variable is not a reliable reflection of the learning curve&#46; On the contrary&#44; the analysis of perioperative complications associated with the technique itself &#40;surgical failure&#41; could be considered a more precise tool for evaluating the acquisition of the technical skills necessary for satisfactory perioperative results&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this study is to analyze the learning curve of robotic anatomical lung resections by evaluating surgical time&#44; surgical failure and cardiorespiratory morbidity using cumulative sum analysis &#40;CUSUM&#41; and risk-adjusted CUSUM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">From June 2018 to March 2020&#44; 73 patients underwent robotic anatomic lung resection using the Da Vinci&#174; system &#40;Model X&#59; Intuitive Surgical&#44; Sunnyvale&#44; CA&#44; USA&#41;&#44; performed by a single surgeon &#40;MJ&#41; at our hospital&#46; Before starting to use the robot for lung resections&#44; the surgeon had performed more than 200 anatomic VATS lung resections and 4 robotic thymectomies&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The selection criteria for patients who were candidates for robotic lung resection were based on the physiological evaluation of the patient recommended by current clinical practice guidelines<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and on the characteristics of the lesion to be resected&#46; Patients who potentially required extended resection &#40;associated with the chest wall&#44; atrium&#44; vena cava&#44; diaphragm&#44; vertebra&#44; Pancoast tumors&#44; sleeve resections&#44; pneumonectomies or intrapericardial pneumonectomy&#41; were not considered for this type of approach&#46; The perioperative management of the patients was uniform throughout the study period&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The surgical technique is based on the use of the 4 robotic arms and an access port&#46; First&#44; we insert the camera through an 8-mm trocar at the 8th intercostal space on the mid-axillary line&#46; The pleural cavity is analyzed with a camera at 0&#176; angulation&#46; Afterwards&#44; we insert two 12-mm robotic trocars at the 8th intercostal space on the anterior axillary line at the insertion of the diaphragm and at the scapular line&#44; respectively&#46; The last robotic trocar is inserted into the 8th intercostal space at the triangle of auscultation and lung segment 6&#46; Last of all&#44; we insert an access port in the 9th intercostal space at the insertion of the diaphragm&#44; just between the camera trocar and the 1st or 3rd trocar&#44; creating an equilateral triangle&#46; The position of this trocar depends on the lobe to be resected&#58; between the camera trocar and the anterior port for the lower lobes&#44; or between the camera trocar and the 3rd trocar for the upper lobes&#46; We use CO<span class="elsevierStyleInf">2</span> insufflation at a pressure of 6&#8722;10&#160;mmHg&#46; The vessels&#44; fissure and bronchus are dissected primarily with bipolar Maryland dissecting forceps&#44; then divided with manual or robotic endostaplers&#46; The surgical specimen is extracted with the help of a retrieval bag&#44; lengthening the most anterior port&#46; Lastly&#44; we insert a 24&#160;F tube through the camera incision&#46; In all cases&#44; a catheter for paravertebral analgesia is placed at the beginning of the procedure under endoscopic guidance&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The learning curve was evaluated based on the following results&#58; surgical time&#44; surgical failure&#44; and postoperative cardiorespiratory complications&#46; The surgical time was defined as the total duration of the procedure &#40;from skin to skin&#41;&#44; which includes both docking time and work time at the surgeon&#8217;s console&#46; The perioperative adverse effects related with the technique &#40;surgical failure&#41; included&#58; intraoperative complications&#44; conversion&#44; re-operation and postoperative complications associated with the technique &#40;hemothorax&#44; prolonged air leak&#44; chylothorax&#44; empyema&#44; recurrent paralysis&#44; wound hematoma&#44; bronchial fistula&#41;&#46; Postoperative cardiorespiratory complications included&#58; respiratory failure&#44; need for reintubation&#44; need for mechanical ventilation &#62;24&#160;h&#44; pneumonia&#44; atelectasis requiring bronchoscopy&#44; acute respiratory distress syndrome&#44; arrhythmia requiring treatment&#44; acute myocardial infarction&#44; acute heart failure&#44; cerebrovascular accident&#44; and acute kidney failure&#46; All complications were defined in advance following the recommendations published in the joint document of the Society of Thoracic Surgeons and the European Society of Thoracic Surgeons&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Based on the results&#44; the learning curve was analyzed using the CUSUM method for continuous variables &#40;surgical time&#41; and the standard CUSUM methods not adjusted for risk and risk-adjusted CUSUM for dichotomous variables &#40;surgical failure and postoperative cardiorespiratory complications&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The surgical time was analyzed using the CUSUM method&#44; which determines the differences of the accumulated total between the individual data and the mean of all the data&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The patients were organized chronologically from the first patient in June 2018 to the last patient in March 2020&#46; Subsequently&#44; the difference was calculated between the result obtained and the mean of all the data for each patient&#46; Finally&#44; the accumulated sum of these differences was defined&#44; and they were represented graphically&#46; Line 0 of the chart represents the reference value that corresponds with the mean surgical time&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical failure was analyzed using the standard CUSUM method &#40;not adjusted for risk&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Given that the basic principle of this type of analysis is to reward or penalize based on the risk of failure&#44; which is constant for each case&#44; before performing the analysis we calculated the risk of surgical failure from the global series&#46; After organizing the patients chronologically according to their result &#40;0&#160;&#61;&#160;no adverse effects and 1&#160;&#61;&#160;adverse effects&#41;&#44; the difference between the result obtained &#40;0 or 1&#41; and the expected result &#40;risk of surgical failure of the entire series&#41; was calculated for each patient&#46; Thus&#44; when the patient did not present surgical failure&#44; the reward obtained was equivalent to the risk of the global series of presenting failure&#58; &#8211; &#40;0&#160;&#8722;&#160;risk of the global series&#41;&#46; However&#44; when a patient presented an adverse effect related to the technique&#44; the penalization was &#8211;&#40;1&#160;&#8722;&#160;risk of the global series&#41;&#46; Last of all&#44; the accumulated sum of these differences was calculated and represented graphically&#46; Line 0 of the chart represents the reference value that corresponds to the general prevalence of surgical failure&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The occurrence of postoperative cardiorespiratory complications was analyzed using the risk-adjusted CUSUM method&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Since this type of analysis considers the heterogeneity of the patients&#8217; clinical characteristics&#44; before performing the analysis&#44; we calculated the individual risk of postoperative cardiorespiratory complications according to the Eurolung 1 risk model&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> After organizing the patients chronologically with their result &#40;0&#160;&#61;&#160;no cardiorespiratory complications&#59; 1&#160;&#61;&#160;cardiorespiratory complications&#41;&#44; the difference between the result obtained &#40;0 or 1&#41; and the expected result &#40;individual risk of complications according to the model&#41; was calculated for each patient&#46; Thus&#44; when the patient did not present any postoperative cardiorespiratory complications&#44; the reward obtained was equivalent to the individual risk of presenting it&#58; &#8211; &#40;0&#160;&#8722;&#160;individual risk of complications according to the model&#41;&#46; However&#44; when the patient presented a complication of this type&#44; the penalization turned out to be &#8211;&#40;1&#160;&#8722;&#160;individual risk of complications according to the model&#41;&#46; Lastly&#44; the accumulated sum of these differences was represented graphically&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The analysis of the demographic and clinical characteristics of the population was carried out using the SPSS&#174; statistical software&#44; version 26 &#40;IBM Corp&#44; Chicago&#44; IL&#44; USA&#44; 2019&#41;&#44; while the CUSUM charts were created with the Excel&#174; program &#40;Microsoft&#44; Redmond&#44; WA&#44; USA&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study included a total of 73 cases&#46; The demographic and clinical characteristics of the patients are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The median duration of all the interventions was 120&#160;min &#40;interquartile range&#58; 90&#8722;150&#160;min&#41;&#46; Seventeen of 73 patients had surgical failure&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the different perioperative adverse effects related to the technique of the series&#46; The prevalence of cardiorespiratory complications was 5&#46;48&#37;&#46; Two atrial fibrillations&#44; one pneumonia and one cerebrovascular accident were registered&#46; The mean risk of cardiorespiratory complications according to the Eurolung 1 model was 7&#46;95&#37;&#46; No deaths were recorded in the series&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">CUSUM charts for surgical time&#44; surgical failure&#44; and postoperative cardiorespiratory morbidity can be seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#44; respectively&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">In the surgical time chart&#44; 2 inflection points were identified in which a change was observed in the trend of the duration of the intervention&#46; The learning curve was divided into 3 stages&#58; I &#40;from the 1st to the 14th procedures&#41;&#44; in which the curve has an upward trend&#44; indicating that the surgical time was greater than the mean of the series&#59; II &#40;between the 15th and 30th procedures&#41;&#44; in which the curve remains relatively stable&#44; indicating that the surgical time was similar to the mean time of the global series&#59; and III &#40;from the 31st surgery on&#41;&#44; in which the curve has a downward trend&#44; indicating that the surgical time was lower than the mean of the global series&#46; In the surgical failure chart&#44; a single inflection point was identified at the 31st procedure&#44; after which the curve showed an upward trend&#44; indicating that the technical competence necessary to ensure satisfactory perioperative results was achieved from this procedure on&#46; In the chart of cardiorespiratory complications&#44; an inflection point was identified at the 22nd intervention&#44; after which the curve showed a continuous upward trend&#44; indicating the absence of complications after this procedure&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Based on the combined analysis of these charts&#44; the learning curve was divided into 3 phases&#58; initial learning &#40;from the 1st to the 14th procedures&#41;&#44; consolidation &#40;between the 15th and the 30th procedures&#41;&#44; and perfecting &#40;from the 31st procedure on&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Robotic surgery is a minimally invasive treatment strategy for thoracic surgical pathology and an alternative approach to VATS&#46; Although several studies have shown that it is a safe and effective technique&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> its implementation requires the evaluation of the surgeon&#8217;s learning curve&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">CUSUM charts are quality control charts that best adapt to the monitoring of clinical care processes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The main advantages of these charts are their simplicity&#44; intuitive visual interpretation&#44; and the ability to detect changes in trends regardless of sample size&#46; Using CUSUM charts&#44; it is possible to monitor the process in real time from its inception&#44; making them useful for studying learning curves&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In our study&#44; the evaluation of surgical time using CUSUM charts allowed us to identify 3 different periods in the surgeon&#8217;s learning curve&#46; However&#44; the surgical time alone is not sufficient to conduct a multidimensional analysis of this curve&#46; Technical competence should consider other surgical outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The analysis of surgical failure&#44; defined as the occurrence of perioperative adverse effects related to the technique&#44; can be a more accurate indicator of the process of acquiring technical skills in robotic surgery&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In addition&#44; our study shows that the occurrence of postoperative cardiorespiratory complications is not a useful indicator for evaluating the learning curve because of the low frequency of these events &#40;only 4 in our series&#41; and because they are more dependent on the intrinsic characteristics of patients than on the technical competence of the surgeon&#46; Nonetheless&#44; it is true that most of these complications occurred at the beginning of the second phase&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The results of our study are consistent with those obtained in previous analyses&#46; Meyer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> analyzed the robotic lobectomy learning curve in a series of 185 patients based on surgical time&#44; mortality&#44; and surgeon comfort&#44; setting the learning curve at 15&#44; 20 and 19 cases&#44; respectively&#46; Song et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> analyzed the learning curve of robotic lobectomy for lung cancer in a series of 208 patients using CUSUM analysis based on docking duration&#44; console time and total procedure time&#44; establishing the learning curve at 20&#44; 34 and 32 cases&#44; respectively&#46; Toker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> analyzed the results of 102 robotic anatomical resections&#44; including lobectomies and segmentectomies&#44; and established the duration of the learning curve at 14 cases&#46; Meanwhile&#44; Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> studied the learning curve of robotic segmentectomy&#44; observing a decrease in surgical time after the 47th procedure&#44; while the technical competence necessary to ensure satisfactory perioperative results was achieved after the 40th procedure&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The main limitation of this study is based on the possible heterogeneity of the operated patients in terms of surgical complexity&#44; which is often not assessable preoperatively&#46; Second&#44; the sample size is relatively small to evaluate all levels of surgical complexity&#46; Third&#44; the surgeon had extensive experience in VATS lung resections and some degree of robotic experience&#44; so the learning curve could be longer in surgeons without this type of prior experience&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study demonstrates that the learning curve for robotic anatomical lung resections can be divided into 3 phases&#58; the first 14 interventions were part of the initial learning period&#44; the next 16 interventions were the consolidation phase&#44; and the refinement period started at the 31st procedure&#46; The technical competence that ensures satisfactory perioperative results was achieved in phase III&#44; starting with the 31st procedure&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no direct or indirect conflicts of interests related with the content of this manuscript&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Robotic surgery has become a safe and effective approach for the treatment of pulmonary surgical pathology&#46; However&#44; the adoption of new surgical techniques requires the evaluation of the learning curve&#46; The objective of this study is to analyze the learning curve of robotic anatomical lung resections&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Retrospective analysis of all robotic anatomical lung resections performed by the same surgeon between June 2018 and March 2020&#46; The learning curve was evaluated using CUSUM charts to estimate trend changes in surgical time&#44; surgical failure and the occurrence of post-operative cardiorespiratory complications throughout the sequence of cases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The study included a total of 73 cases&#46; The median duration of all complications was 120&#160;min &#40;interquartile range&#58; 90&#8722;150&#160;min&#41;&#44; the prevalence of surgical failure was 23&#46;29&#37;&#44; while 4&#47;73 patients had any postoperative cardiorespiratory complication&#46; Based on the CUSUM analysis&#44; the learning curve was divided into 3 different phases&#58; phase <span class="elsevierStyleSmallCaps">i</span> &#40;from the first to the 14th intervention&#41;&#44; phase <span class="elsevierStyleSmallCaps">ii</span> &#40;between the 15th and 30th intervention&#41; and phase <span class="elsevierStyleSmallCaps">iii</span> &#40;from the 31st intervention&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The learning curve for robotic anatomical lung resections can be divided into 3 phases&#46; The technical competence that guarantees satisfactory perioperative outcomes was achived in phase <span class="elsevierStyleSmallCaps">iii</span> from the 31st intervention&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a rob&#243;tica se ha convertido en una v&#237;a de abordaje segura y efectiva para el tratamiento de la patolog&#237;a quir&#250;rgica pulmonar&#46; Sin embargo&#44; la adopci&#243;n de nuevas t&#233;cnicas quir&#250;rgicas requiere de la evaluaci&#243;n de la curva de aprendizaje&#46; El objetivo de este estudio es analizar la curva de aprendizaje de las resecciones pulmonares anat&#243;micas por v&#237;a rob&#243;tica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de todas las resecciones pulmonares anat&#243;micas por v&#237;a rob&#243;tica realizadas por un mismo cirujano entre junio de 2018 y marzo de 2020&#46; La curva de aprendizaje se evalu&#243; utilizando gr&#225;ficas CUSUM para estimar los cambios en la tendencia del tiempo y los fallos quir&#250;rgicos y la aparici&#243;n de complicaciones cardiorrespiratorias postoperatorias a lo largo de la secuencia de casos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">El estudio incluy&#243; un total de 73 casos&#46; La mediana de duraci&#243;n de todas las intervenciones fue de 120&#160;min &#40;rango intercuart&#237;lico&#58; 90&#8722;150&#160;min&#41;&#44; la prevalencia de fallo quir&#250;rgico fue del 23&#44;29&#37;&#44; mientras que 4&#47;73 pacientes presentaron alguna complicaci&#243;n cardiorrespiratoria postoperatoria&#46; Con base en el an&#225;lisis CUSUM&#44; la curva de aprendizaje fue dividida en 3 fases diferentes&#58; fase <span class="elsevierStyleSmallCaps">i</span> &#40;desde la primera hasta la 14&#46;<span class="elsevierStyleSup">a</span> intervenci&#243;n&#41;&#44; fase <span class="elsevierStyleSmallCaps">ii</span> &#40;entre la 15&#46;<span class="elsevierStyleSup">a</span> y la 30&#46;<span class="elsevierStyleSup">a</span> intervenci&#243;n&#41; y fase <span class="elsevierStyleSmallCaps">iii</span> &#40;a partir de la 31&#46;<span class="elsevierStyleSup">a</span> intervenci&#243;n&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La curva de aprendizaje para las resecciones pulmonares anat&#243;micas por v&#237;a rob&#243;tica puede dividirse en 3 fases&#46; La competencia t&#233;cnica que asegura resultados perioperatorios satisfactorios se consigui&#243; en la fase <span class="elsevierStyleSmallCaps">iii&#44;</span> a partir de la 31&#46;<span class="elsevierStyleSup">a</span> intervenci&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez Hern&#225;ndez MT&#44; Fuentes Gago M&#44; Novoa Valent&#237;n N&#44; Rodr&#237;guez Alvarado I&#44; Jim&#233;nez L&#243;pez MF&#46; Resecciones pulmonares anat&#243;micas por v&#237;a rob&#243;tica&#58; an&#225;lisis de la curva de aprendizaje&#46; Cir Esp&#46; 2021&#59;99&#58;421&#8211;427&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CUSUM chart for surgical time &#8211; The chart represents each procedure in the series&#44; in chronological order from left to right&#46; Two inflection points are observed in the curve&#58; cases 15 and 31 &#40;in red&#41;&#46; This allowed us to identify 3 stages&#58; stage I &#40;from the 1st to the 14th procedures&#41;&#44; in which the curve has an upward trend&#44; indicating that the surgical time was greater than the mean of the series&#59; stage II &#40;between the 15th and 30th procedures&#41;&#44; in which the curve remains relatively stable&#44; indicating that the surgical time was similar to the mean time of the global series&#59; and stage III &#40;from the 31st procedure on&#41;&#44; in which the curve has a downward trend&#44; indicating that the surgical time was lower than the mean of the global series&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Risk-adjusted CUSUM chart for the occurrence of postoperative cardiorespiratory complications &#8211; The chart represents each procedure in the series&#44; in chronological order from left to right&#44; with the curve moving downward in the event of cardiorespiratory complications and upward in the absence of these&#46; A single inflection point was identified at the 22nd procedure &#40;in red&#41;&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; yrs</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">62&#46;52&#160;&#177;&#160;9&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">BMI&#44; kg</span>&#47;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
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                  \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">26&#46;38&#160;&#177;&#160;5&#46;02&nbsp;\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="elsevierStyleItalic">FEV<span class="elsevierStyleInf">1</span>&#37;&#44;ppo</span>&nbsp;\t\t\t\t\t\t\n
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                  \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">80&#46;08&#160;&#177;&#160;21&#46;5&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">DLCO&#37;&#44;ppo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#46;33&#160;&#177;&#160;18&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Coronary disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cerebrovascular disease</span>&nbsp;\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 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes</span>&nbsp;\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 &#40;4&#46;1&#41;&nbsp;\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="elsevierStyleItalic">Hypertension</span>&nbsp;\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">18 &#40;24&#46;7&#41;&nbsp;\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
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                  \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 &#40;2&#46;7&#41;&nbsp;\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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previous neoplasm</span>&nbsp;\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">32 &#40;43&#46;8&#41;&nbsp;\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 " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of resection</span></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>Lobectomy&nbsp;\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">56 &#40;76&#46;7&#41;&nbsp;\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>Segmentectomy&nbsp;\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">17 &#40;23&#46;3&#41;&nbsp;\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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diagnosis</span></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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lung carcinoma&nbsp;\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">58 &#40;79&#46;5&#41;&nbsp;\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>Metastasis of extrapulmonary origin&nbsp;\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">8 &#40;11&#41;&nbsp;\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>Benign&nbsp;\t\t\t\t\t\t\n
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                  \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">7 &#40;9&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \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 &#40;4&#46;11&#41;&nbsp;\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>Bronchial lesion&nbsp;\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 &#40;2&#46;74&#41;&nbsp;\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>Air leak&nbsp;\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 &#40;1&#46;37&#41;&nbsp;\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="elsevierStyleItalic">Conversion</span>&nbsp;\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 &#40;4&#46;11&#41;&nbsp;\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>Bronchial lesion&nbsp;\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 &#40;2&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Air leak&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Re-operation</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;5&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Technical postoperative complications</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;2&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;9&#46;59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;2&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;1&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;1&#46;37&#41;&nbsp;\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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;2&#46;74&#41;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bronchial fistula&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;1&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
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