Oxidative stress in dogs with chronic inflammatory enteropathy treated with allogeneic mesenchymal stem cells.

The search for new biomarkers in patients with chronic inflammatory enteropathy (CIE) is ongoing in the human and veterinary medicine fields. Oxidative stress biomarkers (malondialdehyde [MDA], reduced glutathione [GSH], and albumin) have been studied in humans with chronic enteropathies, but among them, only albumin has been studied in dogs with CIE. Moreover, the effect of mesenchymal stem cell (MSCs) treatment with or without prednisone on these parameters has never been studied in dogs with CIE. These parameters were compared between healthy dogs (n = 12) and dogs with CIE, and before and 1, 3, 6, and 12 months after the treatment with MSCs alone (n = 9) or together with prednisone (n = 11). The relationship between the Canine Inflammatory Bowel Disease Activity Index (CIBDAI) and oxidative stress was evaluated. Albumin was the only parameter that significantly differed between dogs with CIE and healthy dogs (p = 0,037). Differences were observed only in albumin values after combined treatment with MSCs and prednisone. No differences were observed in MDA and GSH after treatment with MSCs with or without prednisone. Albumin could help stage canine CIE, as well as its prognosis, as has already been demonstrated, although it is essential to evaluate this parameter for its antioxidant capacity, and therefore it could be a good biomarker of oxidative stress in this pathology. However, the treatment with MSCs seems unable to modify any of the analyzed oxidative stress parameters.

The impact of the transversus abdominis plane block (TAP) on stress response measured through the complete blood- derived inflammatory markers.

This study aims to evaluate the effect of the transversus abdominis plane (TAP) block on the blood cells and the inflammatory markers neutrophil- to- lymphocyte ratio (NLR), platelet- to- lymphocyte ratio (PLR), and systemic immune- inflammation index (SII) after the laparoscopic ovariectomy (LapOV) in dogs. 72 healthy bitches undergoing LapOV were randomly allocated to the no- TAP group of dogs under inhaled anesthesia (IA), the TAP- S group (IA and TAP with saline), and the TAP- B group (IA and TAP with bupivacaine). The NLR, PLR, and SII were calculated 1 h before ovariectomy (T0) and at 2-3 h (T1), 6-8 h (T2), and 20-24 h (T3) post- surgery. The number of dogs requiring postoperative analgesic rescue with buprenorphine and the doses administered in each group were recorded. Significant changes were observed in all groups' postoperative NLR, PLR, and SII over time. Between groups, no differences were observed in any of the ratios at any control point (NLR at T0-T3: p = 0.17, 0.36, 0.80, and 0.95; PLR at T0-T3: p = 0.70, 0.62, 0.21, 0.87; SII at T0-T3: p = 0.29, 0.65, 0.09, and 0.34). A significantly lower number of dogs required analgesic rescue in the TAP-B group (p = 0.0001) and a lower number of doses were administered (p = 0.001). There is no difference in the inflammatory response measured through the complete blood- derived inflammatory markers after the LapOV in dogs when the postoperative pain is managed entirely with opioids or with the TAP block with bupivacaine. The hydrodissection associated with the TAP block technique does not increase the inflammatory response.

Using complete blood count-derived inflammatory markers to compare postoperative inflammation in dogs undergoing open or laparoscopic ovariectomy.

BACKGROUND: The inflammatory response triggered in dogs after laparoscopic ovariectomy (LapOV) or ovariectomy through mini-celiotomy (COV) has never been compared using the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammatory index (SII). METHODS: Bitches underwent LapOV (n = 25) or COV (n = 25). NLR, PLR and SII were calculated 1 hour before ovariectomy (T0) and 2-3, 6-8 and 20-24 hours (T1-T3) after surgery. RESULTS: Surgical time was longer in the LapOV group. Changes over time were observed in the NLR, PLR and SII in both groups (p < 0.001). PLR at baseline and T1 (p = 0.03 and 0.01) and NLR, PLR and SII at T2 (p = 0.01, 0.01 and 0.009) were higher in the LapOV group than in the COV group, but they did not differ at T3. LIMITATIONS: The overrepresentation of Greyhounds in the LapOV group and the short-term follow-up are the study's main limitations. CONCLUSION: Although an inflammatory peak was observed 6-8 hours after COV or LapOV, it was higher after the laparoscopy. However, there was no difference in the bitches' inflammatory status 24 hours after surgery.

Evaluation of the Two-Point Ultrasound-Guided Transversus Abdominis Plane Block for Laparoscopic Canine Ovariectomy.

The transversus abdominis plane (TAP) block causes desensitization of the abdominal wall and peritoneum. Of all the approaches proposed to perform it, the two-injection-point TAP showed the best results in terms of the area reached by the anesthetic solution. However, to date, no clinical data exist. The aim of this study was to evaluate the intra- and postoperative analgesic efficacy of a two-injection-point TAP block in dogs undergoing laparoscopic ovariectomy. A total of 26 animals were assigned to receive general inhalation anesthesia (control group), and 26 dogs were assigned to general inhalation anesthesia combined with TAP block (TAP group). The ultrasound-guided TAP block was carried out with a subcostal and cranial-to-ilium injection per hemiabdomen. The end-tidal concentration of isoflurane (EtISO) was recorded at different moments during the surgery. Postoperative pain was assessed at different time points during the first 24 h after surgery. The control group required significantly higher EtISO concentration during the ovarian resection and showed higher postoperative pain scores than the TAP group. Fewer dogs in the TAP group required intra- or postoperative rescue analgesia. TAP block can be implemented to improve postoperative pain management after laparoscopy, reducing the dosage of the systemic drugs used and, hence, their possible side effects.

Complete Blood Count-Derived Inflammatory Markers Changes in Dogs with Chronic Inflammatory Enteropathy Treated with Adipose-Derived Mesenchymal Stem Cells.

Adipose-derived mesenchymal stem cells (Ad-MSCs) exhibit anti-inflammatory and immunomodulatory activities. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have been reported as novel biomarkers of the inflammatory state; however, they have never been examined in dogs with chronic inflammatory enteropathy (CIE) treated with Ad-MSCs. This study aimed to compare the clinical evolution and the changes in the NLR, PLR, and SII in dogs with CIE before and after cell therapy. Sixteen dogs with CIE were administered a single intravenous dose of Ad-MSCs. The canine chronic enteropathy clinical activity index (CCECAI), NLR, PLR, and SII were assessed before treatment (T0) and at 2 (T2) and 9 (T9) months post-treatment and compared over time and with the reference values obtained from a group of healthy dogs. NLR, PLR, and SII were significantly increased at T0 compared to the reference values, decreasing significantly over time. At T9, the NLR and SII did not differ from the reference values, but PLR remained above the reference values. A correlation was observed between CCECAI and the three markers. These findings show that the clinical improvement of dogs with CIE treated with Ad-MSCs is accompanied by a normalization of the inflammatory status.

Relationship between serum cobalamin concentration and endoscopic ileal appearance and histology in dogs with chronic inflammatory enteropathy.

BACKGROUND: It has not been determined whether ileal appearance differs among dogs with chronic inflammatory enteropathy (CIE) and different serum concentrations of cobalamin. OBJECTIVE: To compare endoscopic and histologic ileal findings in dogs with CIE and different serum cobalamin concentrations and then evaluate the correlation of ileal changes to cobalamin serum concentration using updated scoring systems to assess the ileum. ANIMALS: Sixty-eight dogs with CIE. METHODS: Retrospective study. Frequency of ileal features and ileal histologic and endoscopic scores (IHS and IES) were obtained and compared among CIE dogs with severe hypocobalaminemia (SHC; <200 ng/L), hypocobalaminemia (HC; 200-350 ng/L), or normocobalaminemia (NC; >350 ng/L). The correlation of IHS and IES with cobalamin was evaluated. RESULTS: Friability, villus atrophy, crypt dilatation, epithelial injury, and intraepithelial lymphocytes were more frequent in SHC than in NC dogs (all P ≤ .01). Median SHC-IES (2; range, 0-4) was higher than NC-IES (1; range, 0-5; P = .004). Median SHC-IHS (6; range, 3-9) was higher than HC-IHS (4; range, 1-7; P < .001) and NC-IHS (3; range, 1-8; P < .001). Cobalamin concentration correlated negatively with IES (ρ = -.34, P = .005) and IHS (ρ = -.58, P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE: Ileal features and involvement degree markedly differed when cobalamin was <200 or >350 ng/L in CIE dogs. With updated scales to assess the mucosa, greater ileal damage was associated with lower serum cobalamin concentration.

Effects of Allogeneic Mesenchymal Stem Cell Transplantation in Dogs with Inflammatory Bowel Disease Treated with and without Corticosteroids.

Mesenchymal stem cells have proven to be a promising alternative to conventional steroids to treat canine inflammatory bowel disease (IBD). However, their administration requires a washout period of immunosuppressive drugs that can lead to an exacerbation of the symptoms. Therefore, the feasibility and effects of the combined application of stem cells and prednisone in IBD-dogs without adequate response to corticosteroids was evaluated for the first time in this study over a long- term follow up. Two groups of dogs with IBD, one without treatment and another with prednisone treatment, received a single infusion of stem cells. The clinical indices, albumin and cobalamin were determined prior to the infusion and after one, three, six and 12 months. In both groups, all parameters significantly improved at each time point. In parallel, the steroid dosage was gradually reduced until it was suppressed in all patients a year after the cell therapy. Therefore, cell therapy can significantly and safely improve the disease condition in dogs with IBD receiving or not receiving prednisone. Furthermore, the steroid dosage can be significantly reduced or cancelled after the stem cell infusion. Their beneficial effects are stable over time and are long lasting.

Comparison of the use of fresh-frozen canine cadavers and a realistic composite ex vivo simulator for training in small animal flexible gastrointestinal endoscopy.

OBJECTIVE To compare the usefulness of fresh-frozen canine cadavers (FFCCs) and a validated canine simulator model for training veterinary students in basic gastrointestinal endoscopic procedures. DESIGN Randomized trial. SAMPLE 48 veterinary students in their final year of training. PROCEDURES Students were randomly assigned to receive basic gastrointestinal endoscopic training on a canine simulator or FFCC. All students were trained as assigned in esophagogastroduodenoscopy, endoscopic gastric biopsy, and gastric foreign body removal for 2 h/d for 5 days. They then performed each procedure on a live dog, and procedure completion time and performance ability were compared between groups. Two experienced endoscopists used a validated Likert-type procedural rating scale to rate the students' performance. Students completed a survey to rate their training model. RESULTS No significant differences were identified between groups in quality of performance of the 3 endoscopic procedures on a live dog. Students required significantly less time to complete the procedures on a live dog when trained on an FFCC versus canine simulator. Although both training models were considered equally useful by students, training on the simulator was significantly more stimulating. CONCLUSIONS AND CLINICAL RELEVANCE Students showed the same skill level in performing basic endoscopic procedures on live dogs regardless of the training model used, although students who trained on the FFCC completed these procedures faster than students trained on the canine simulator. Use of the simulator appeared to be a viable alternative to use of FFCCs for veterinary endoscopic training, providing students with a good level of proficiency before performing endoscopic procedures on live dogs.

Canine laparoscopic ovariectomy using two 3- and 5-mm portal sites: A prospective randomized clinical trial.

Laparoscopic ovariectomy (LapOve) was performed in 3 groups (2.7-mm/5-mm, 5-mm/3-mm, and 5-mm telescope/5-mm bipolar forceps) of small dogs (n = 60). Surgical times, bleeding rates, complications, and laparoscopic visualization were recorded and compared among groups. Use of the 3-mm bipolar forceps significantly increased the surgical time and showed higher bleeding rates compared with the 5-mm bipolar forceps. The 2.7-mm telescope significantly decreased the laparoscopic view. No complications were seen in any group. In conclusion, the 2.7-mm 30° telescope or the 3-mm bipolar forceps combined with the 5-mm instruments could be used as an alternative technique for LapOve in dogs up to 10 kg. The 2.7-mm telescope with the 5-mm bipolar forceps was the most efficient combination based on surgical time.

Ovariectomie laparascopique canine en utilisant deux sites d'accès de 3 et de 5 mm : un essai clinique randomisé prospectif. Une ovarioectomie laparoscopique (LapOve) a été réalisée dans 3 groupes (forceps bipolaires 2,7-mm/télescope 5-mm, 5-mm/3-mm et 5-mm/5-mm) de petits chiens (n = 60). La durée de la chirurgie, les taux de saignement, les complications et la visualisation laparoscopique ont été consignés et comparés entre les groupes. L'usage des forceps bipolaires de 3 mm a augmenté significativement la durée de la chirurgie et a affiché des taux de saignement supérieurs comparativement aux forceps bipolaires de 5 mm. Le télescope de 2,7 mm a significativement réduit la vue laparascopique. Des complications n'ont pas été observées dans aucun groupe. En conclusion, le télescope 30° de 2,7 mm ou les forceps bipolaires de 3 mm combinés aux instruments de 5 mm pourraient être utilisés comme technique de remplacement pour la LapOve chez les chiens pesant jusqu'à 10 kg. Le télescope de 2,7 mm avec le forceps bipolaire de 5 mm était la combinaison la plus efficace basée sur la durée de la chirurgie.(Traduit par Isabelle Vallières).

Gastroesophageal reflux in anesthetized dogs: a review / Reflujo gastroesofágico en perros anestesiados: revisión de literatura / Refluxo gastroesofágico em cães anestesiados: revisão de literatura

Gastroesophageal reflux can be a catastrophic illness in small animals during anesthesia since its complications can cause serious pathologies, such as esophagitis, esophageal stenosis and aspiration pneumonia. With an incidence from 12 to 78.5% in anesthetized dogs, gastroesophageal reflux is normally silent during anesthesia and will be notices only if regurgitation occurs and stomach acid is present in the nasal or oral cavities. In humans, gastroesophageal reflux disease (GERD) is a well-defined pathology where the lower esophageal sphincter has a sustained weakness. However, in dogs, gastroesophageal reflux disease as such is not well established, if at all; it has only been described as gastroesophagic reflux, occurring principally in anesthetized animals. There are several factors influencing the presentation of reflux in anesthetized dogs, which may be inherent to the patient (e.g. age, sex, breed, weight, or body condition), medications used prior to and during anesthesia, type of surgery or position of the animal during surgery. The objective of this review is to discuss a series of conditions that could predispose dogs to gastroesophageal reflux during anesthesia and to assist in the prevention and diagnosis of this condition.

El reflujo gastroesofágico durante la anestesia puede ser una entidad catastrófica en la clínica de pequeñas especies, ya que sus complicaciones derivan en entidades realmente graves como esofagitis, estenosis esofágica y neumonía por aspiración. Con una incidencia del 12 al 78.5% en perros anestesiados, el reflujo gastroesofágico durante la anestesia es generalmente silencioso y sólo se observa cuando existe regurgitación y el reflujo pasa a cavidad oral o nasal. En el humano, la enfermedad por reflujo gastroesofágico (ERGE) es una patología bien definida, donde el esfínter esofágico inferior presenta una debilidad sostenida. Sin embargo, en el perro esta enfermedad como tal no está bien establecida, si acaso se describe el reflujo gastroesofágico, que ocurre principalmente en animales anestesiados. Existen diversos factores que influyen en la presentación del reflujo en los perros anestesiados. Estos pueden ser inherentes al paciente (por ejemplo: edad, sexo, raza, peso o condición corporal), a medicamentos utilizados previamente y durante la anestesia, al tipo de cirugía o a la posición del animal durante la cirugía. El objetivo de esta revisión es discutir una guía de las condiciones que predisponen a la aparición de reflujo gastroesofágico durante la anestesia en perros con el fin de facilitar el diagnóstico y la prevención de esta condición.

O refluxo gastroesofágico durante a anestesia pode ser uma entidade catastrófica na clínica de pequenas espécies, já que suas complicações resultam em entidades realmente graves, como esofagite, estenose esofágica e pneumonia por aspiração. O refluxo gastroesofágico em cães anestesiados é geralmente silencioso, com uma incidência de 12 até 78.5% e só é observada quando há regurgitação e o refluxo passa até a cavidade oral ou nasal. Nos humanos, a doença pelo refluxo gastroesofágico (ERGE) é uma patologia bem definida, onde o esfíncter esofágico inferior apresenta uma debilidade continua. Porém, esta doença em cães não está bem estabelecida, pelo qual só se descreve o refluxo gastroesofágico, que ocorre principalmente em animais anestesiados. Existem diversos fatores que influenciam na apresentação do refluxo em cães anestesiados. Estes podem ser inerentes ao paciente (por exemplo: idade, sexo, raça, peso ou condição corporal), a medicamentos utilizados previamente e durante a anestesia, ao tipo de cirurgia ou a posição do animal durante a cirurgia. O objetivo da revisão foi discutir uma guia das condições que predispõem à aparição de refluxo gastroesofágico durante a anestesia em cães com o fim de facilitar o diagnóstico e a prevenção dessa condição.

Validation of a realistic simulator for veterinary gastrointestinal endoscopy training.

This article reports on the face, content, and construct validity of a new realistic composite simulator (Simuldog) used to provide training in canine gastrointestinal flexible endoscopy. The basic endoscopic procedures performed on the simulator were esophagogastroduodenoscopy (EGD), gastric biopsy (GB), and gastric foreign body removal (FBR). Construct validity was assessed by comparing the performance of novices (final-year veterinary students and recent graduates without endoscopic experience, n=30) versus experienced subjects (doctors in veterinary medicine who had performed more than 50 clinical upper gastrointestinal endoscopic procedures as a surgeon, n=15). Tasks were scored based on completion time, and specific rating scales were developed to assess performance. Internal consistency and inter-rater agreement were assessed. Face and content validity were determined using a 5-point Likert-type scale questionnaire. The novices needed considerably more time than the experts to perform EGD, GB, and FBR, and their performance scores were significantly lower (p<.010). Inter-rater agreement and the internal validity of the rating scales were good. Face validity was excellent, and both groups agreed that the endoscopy scenarios were very realistic. The experts highly valued the usefulness of Simuldog for veterinary training and as a tool for assessing endoscopic skills. Simuldog is the first validated model specifically developed to be used as a training tool for endoscopy techniques in small animals.

Development of an optimal diaphragmatic hernia rabbit model for pediatric thoracoscopic training.

Our objectives were to standarize the procedure needed to reproduce a similar surgical scene which a pediatric surgeon would face on repairing a Bochdalek hernia in newborns and to define the optimal time period for hernia development that achieve a realistic surgical scenario with minimimal animal suffering. Twenty New Zealand white rabbits weighing 3-3.5 kg were divided into four groups depending on the time frame since hernia creation to thoracoscopic repair: 48 h, 72 h, 96 h and 30 days. Bochdalek trigono was identified and procedures for hernia creation and thoracoscopic repair were standarized. Blood was collected for hematology (red blood cells, white blood cells, platelets, hemoglobin and hematocrit), biochemistry (blood urea nitrogen, creatinine, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase and creatine kinase) and gas analysis (arterial blood pH, partial pressure of oxygen, partial pressure of carbón dioxide, oxygen saturation and bicarbonate) at baseline and before the surgial repairment. Glucocorticoid metabolites concentration in faeces was measured. Thoracoscopy video recordings were evaluated by six pediatric surgeons and rated from 0 to 10 according to similarities with congenital diaphragmatic hernia in newborn and with its thoracoscopic approach. Statistical methods included the analysis of variance, and comparisons between groups were followed by a post-hoc Tukey's test. Fourty -eight h showed to be the optimal time frame to obtain a diaphragmatic hernia similar to newborn scenario from a surgical point of view with minimal stress for the animals.

Evaluation of a Bochdalek diaphragmatic hernia rabbit model for pediatric thoracoscopic training.

BACKGROUND/AIM: This study evaluated the usefulness of a Bochdalek hernia rabbit model as a tool for advanced thoracoscopic training, teaching the specific skills required for thoracoscopic repair of congenital diaphragmatic hernia. MATERIALS AND METHODS: An incision was made in the Bochdalek triangle of 25 New Zealand rabbits (weighing 3-3.5 kg) to induce an experimental diaphragmatic hernia. At 72 hours later, a thoracoscopic repair of the hernia as described for newborns was performed by 25 pediatric surgeons divided into two groups: expert and novice. The tasks assessed were organ relocation and diaphragm suture. A visual analog scale was used to evaluate technical performance. The objective performance measure was completion time. Complications were recorded, and suture quality was scored. The surgeons evaluated the model by completing a questionnaire, grading items on a 5-point scale. RESULTS: All 25 animals developed a diaphragmatic hernia with protrusion of the intestine into the thoracic cavity. Expert trainees had significantly shorter completion times and better performance scores than novices. Experts also received higher scores for suture quality. Five novices caused perforations or bleeding, but no experts did. The surgeons rated the model positively, highlighting the similarities between the model and newborn hernias and its usefulness for pediatric training programs. CONCLUSIONS: The Bochdalek hernia rabbit model can be used to detect different levels of experience in pediatric thoracoscopy. This realistic and easily reproducible model can help to perfect thoracoscopic skills in a realistic recreation of a pediatric Bochdalek hernia repair.

Ureteral obstruction swine model through laparoscopy and single port for training on laparoscopic pyeloplasty.

This study aims firstly to assess the most adequate surgical approach for the creation of an ureteropelvic juntion obstruction (UPJO) animal model, and secondly to validate this model for laparoscopic pyeloplasty training among urologists. Thirty six Large White pigs (28.29±5.48 Kg) were used. The left ureteropelvic junction was occluded by means of an endoclip. According to the surgical approach for model creation, pigs were randomized into: laparoscopic conventional surgery (LAP) or single port surgery (LSP). Each group was further divided into transperitoneal (+T) or retroperitoneal (+R) approach. Time needed for access, surgical field preparation, wound closure, and total surgical times were registered. Social behavior, tenderness to the touch and wound inflammation were evaluated in the early postoperative period. After ten days, all animals underwent an Anderson-Hynes pyeloplasty carried out by 9 urologists, who subsequently assessed the model by means of a subjective validation questionnaire. Total operative time was significantly greater in LSP+R (p=0.001). Tenderness to the touch was significantly increased in both retroperitoneal approaches, (p=0.0001). Surgeons rated the UPJO porcine model for training on laparoscopic pyeloplasty with high or very high scores, all above 4 on a 1-5 point Likert scale. Our UPJO animal model is useful for laparoscopic pyeloplasty training. The model created by retroperitoneal single port approach presented the best score in the subjective evaluation, whereas, as a whole, transabdominal laparoscopic approach was preferred.

[Pyramid training model in laparoscopic surgery]. / Modelo de formación piramidal para la enseñanza de cirugía laparoscópica.

BACKGROUND: Minimally invasive surgery implementation requires a regulated and orderly learning process. METHODS: Jesús Usón Minimally Invasive Surgery Centre promotes a pyramid training model structured into four levels: training of basic and advanced skills in physical simulator (level 1), training of anatomical protocols and advanced skills with animal models (level 2) training advanced procedural skills with tele-surgical applications (level 3), and training in the operating room (level 4). Training provided at levels 1 and 2 is described and evaluated. RESULTS: 4284 participants have been trained in laparoscopy at our institution. 95.5% surgeons: 49% gastroenterologists, 30% urologists, and 14% gynecologist (14%). 77% of celebrated courses consisted of 20 hours training (8 at level 1 and 12 at level 2). 94.37% of participants considered pyramid model as highly suitable, scoring 9.5 on a scale 1-10 for the model and for the simulation quality. 82.7% perceived the improvement in their laparoscopic skills and 99.56% recommend this training program to other surgeons. DISCUSSION: There are no unified criteria between different training programs but most of them measure laparoscopic skills based on time of execution, quality or mistakes of the exercise, and the student satisfaction test. CONCLUSION: The pyramid training model lead to the acquisition of necessary laparoscopic skills to perform safely advanced minimally invasive techniques.

Antecedentes: la práctica de la cirugía de mínima invasión necesita que el aprendizaje sea estructurado y progresivo. Material y métodos: estudio prospectivo efectuado en el Centro de Cirugía de Mínima Invasión Jesús Usón que propone un modelo de formación piramidal con cuatro niveles: adquisición de habilidades básicas en simulador (nivel 1), desarrollo de técnicas quirúrgicas específicas en modelos animales (nivel 2), telemedicina y telementorización (nivel 3), y aplicación al paciente con supervisión experimentada (nivel 4). Objetivo: describir los niveles 1 y 2 que se practican en el Centro y evaluar la formación impartida. Resultados: 4,284 alumnos han recibido formación en cirugía laparoscópica: 95.5% médicos: cirujanos del aparato digestivo (49%), urólogos (30%) y ginecólogos (14%). En 77% de los cursos celebrados disponen de 20 horas de adiestramiento, 8 en el nivel 1, y 12 en el nivel 2. El 94.37% considera altamente apropiado el modelo de formación piramidal, calificándolo con 9.58 sobre 10 y con 9.5 a la calidad de la simulación. El 82.75% percibe que ha avanzado notablemente en sus destrezas y 99.56% recomendaría a otros cirujanos la realización de actividades en el Centro. Conclusión: el modelo de formación propuesto permite alcanzar las habilidades necesarias para efectuar correctamente procedimientos avanzados en cirugía de mínima invasión.