doi: 10.56294/saludcyt2024745

REVIEW

Advancements in Minimally Invasive Surgical Techniques: A Comprehensive Review

Avances en técnicas quirúrgicas mínimamente invasivas: una revisión integral

Andrea Patricia Pérez Ayme¹ *, Josseline María Caiza Suárez¹ *, Martin Mateo Paredes Ortega² *, Daniel Samuel Gualoto Gualoto¹ *, Juan Carlos Santillán Lima³ *, Adriana Elizabeth Rivera Campoverde¹ *, Alfredo Augusto Rivera Ticona⁴ *, Jonathan Steven Coello Vergara⁵ *, Gerzon David Martínez Serrano⁶

¹Escuela Superior Politécnica de Chimborazo, Chimborazo, Ecuador.

²Universidad Regional Autónoma de los Andes (UNIANDES), Ambato, Tungurahua, Ecuador.

³Universidad Nacional de la Plata, Buenos Aires, Argentina.

⁴Universidad Católica de Santa María, Arequipa, Perú.

⁵Universidad de Especialidades Espíritu Santo, Guayaquil, Ecuador.

⁶Universidad Técnica de Ambato, Tungurahua, Ecuador.

Cite as: Pérez Ayme AP, Caiza Suárez JM, Paredes Ortega MM, Gualoto Gualoto DS, Santillán Lima JC, Rivera Campoverde AE, Rivera Ticona AA, Coello Vergara JS, Martínez Serrano GD. Advancements in Minimally Invasive Surgical Techniques: A Comprehensive Review. Salud, Ciencia y Tecnología. 2024; 4:745. https://doi.org/10.56294/saludcyt2024745

Submitted: 30-11-2023                       Revised: 07-01-2023                                       Accepted: 17-02-2024                       Published: 18-02-2024

Editor: Dr. William Castillo-González

ABSTRACT

Introduction: Minimally Invasive Surgical (MIS) techniques have revolutionized the field of surgery, offering significant benefits over traditional open surgery. This narrative review examines the historical evolution, current advancements, and prospects of MIS, with a focus on its impact on patient outcomes, surgical training, and healthcare systems.

Objective: to provide a comprehensive overview of the advancements in MIS, highlighting technological innovations, changes in clinical practice, and the evolution of surgical education. The review also aims to discuss the challenges and future directions of MIS.

Methods: the review included 24 articles published from 2004 to 2023. Criteria for inclusion were relevance to MIS development and impact, with exclusion for non-English and unrelated articles. Data were synthesized to outline the progression, current state, and future trends in MIS.

Results: key findings include significant advancements in surgical technologies such as robotics and enhanced imaging, the expansion of MIS across various specialties, and improved patient outcomes like reduced recovery times and lower complication rates. Challenges identified include the steep learning curve for surgeons and disparities in global access to MIS. Future trends indicate a move towards AI integration, personalized surgical approaches, and further refinement of robotic systems.

Conclusions: MIS represents a paradigm shift in surgical practice, characterized by technological innovation and improved patient care. Despite challenges, its future is promising, with continuous advancements expected to further reshape surgical procedures.

Keywords: Minimally Invasive Surgical Procedures; Robotic Surgical Procedures; Surgical Education; Patient Outcome Assessment.

RESUMEN

Introducción: las técnicas quirúrgicas mínimamente invasivas (TMI) han revolucionado el campo de la cirugía, ofreciendo importantes beneficios sobre la cirugía abierta tradicional. Esta revisión narrativa examina la evolución histórica, los avances actuales y las perspectivas de MIS, centrándose en su impacto en los resultados de los pacientes, la capacitación quirúrgica y los sistemas de atención médica.

Objetivo: proporcionar una descripción general completa de los avances en TMI, destacando las innovaciones tecnológicas, los cambios en la práctica clínica y la evolución de la educación quirúrgica. La revisión también tiene como objetivo discutir los desafíos y las direcciones futuras de TMI.

Métodos: la revisión incluyó 24 artículos publicados entre 2004 y 2023. Los criterios de inclusión fueron la relevancia para el desarrollo y el impacto de TMI, con exclusión de artículos que no estuvieran en inglés y no relacionados. Los datos se sintetizaron para delinear la progresión, el estado actual y las tendencias futuras en TMI.

Resultados: los hallazgos clave incluyen avances significativos en tecnologías quirúrgicas como la robótica y las imágenes mejoradas, la expansión de MIS en varias especialidades y mejores resultados para los pacientes, como tiempos de recuperación reducidos y tasas de complicaciones más bajas. Los desafíos identificados incluyen la pronunciada curva de aprendizaje para los cirujanos y las disparidades en el acceso global a TMI. Las tendencias futuras indican un movimiento hacia la integración de la IA, enfoques quirúrgicos personalizados y un mayor refinamiento de los sistemas robóticos.

Conclusiones: las TMI representan un cambio de paradigma en la práctica quirúrgica, caracterizado por la innovación tecnológica y la mejora de la atención al paciente. A pesar de los desafíos, su futuro es prometedor y se espera que los avances continuos remodelen aún más los procedimientos quirúrgicos.

Palabras clave: Procedimientos Quirúrgicos Mínimamente Invasivos; Procedimientos Quirúrgicos Robóticos; Educación Quirúrgica; Evaluación de Resultados del Paciente.

INTRODUCTION

In recent decades, the field of surgery has undergone a remarkable transformation, driven by rapid technological advancements and a growing emphasis on patient-centered care. This has led to the development and refinement of minimally invasive surgical techniques, which stand at the forefront of modern surgical practice. Minimally invasive surgery (MIS) encompasses a range of procedures designed to minimize tissue damage, reduce patient discomfort, and expedite recovery, thereby improving overall clinical outcomes.⁽¹⁾

The evolution of MIS can be traced back to the pioneering efforts in laparoscopic surgery in the late 20th century, which revolutionized procedures such as cholecystectomies and appendectomies. Since then, the scope of MIS has expanded exponentially, encompassing not only general surgery but also specialties like orthopedics, neurosurgery, and cardiovascular surgery. This narrative review aims to provide a comprehensive overview of the advancements in minimally invasive surgical techniques, tracing their historical development, current applications, and future potential.^(2,3)

Central to the progress in MIS are technological innovations such as enhanced imaging modalities, robotic assistance, and improved surgical instruments, which have collectively broadened the range of feasible procedures while augmenting precision and safety. Additionally, the integration of computer-assisted navigation and telemedicine has further extended the capabilities of MIS, making complex surgeries more accessible and less invasive.^(1,2)

This review also addresses the challenges and limitations of MIS, including the steep learning curve for surgeons, the potential for over-reliance on technology, and the need for evidence-based approaches to validate new techniques. Furthermore, we explore the economic and ethical considerations, particularly in relation to accessibility and disparities in healthcare delivery.⁽⁴⁾ Through this comprehensive review, we highlight the transformative impact of MIS on patient care and the ongoing evolution of surgical practice in the 21st century.

Methods

Scope and Aim of the Review: This narrative review was conducted with the aim of compiling and synthesizing information on the historical evolution, current state, and prospects of MIS techniques.

Data Sources and Search Strategy: A systematic search was conducted across multiple medical and scientific databases, including PubMed, MEDLINE, Cochrane Library, and Google Scholar. The search included 24 articles published in English from 2004 to 2023. Keywords and phrases used in the search included "minimally invasive surgery," "laparoscopy," "robotic surgery," "endoscopic surgery," and specific terms related to MIS in various medical specialties.

Inclusion and Exclusion Criteria: Included in the review were articles that provided insights into the development of MIS techniques, technological advancements, clinical outcomes, training and education implications, and future trends. Exclusion criteria were articles not directly related to MIS, articles focusing on traditional open surgical techniques, and non-English publications.

Data Extraction and Synthesis: Data extraction was conducted by a team of researchers with expertise in surgery and medical review literature. The data were then synthesized to create a narrative that traced the chronological development of MIS, highlighted significant technological advancements, and discussed the impact on patient outcomes and healthcare systems.

Analysis of Technological Advancements: A specific focus was given to the analysis of technological advancements in MIS. This included the evolution of surgical instruments, imaging techniques, robotic systems, and computer-assisted navigation. The review also examined the role of these technologies in enhancing surgical precision, reducing complications, and improving training methods.

Assessment of Training and Educational Impact: The review assessed the impact of MIS on surgical training and education. This involved analyzing changes in training curricula, the adoption of simulation-based training, and the challenges faced by surgeons transitioning from open to minimally invasive techniques.

Ethical and Socio-Economic Considerations: An analysis of the ethical and socio-economic considerations surrounding MIS was conducted. This included access to MIS in different regions, cost implications, and the ethical challenges of implementing new technologies in surgery.

Limitations of the Review: The limitations of this narrative review were acknowledged, including potential publication bias, the variability in study designs of the included articles, and the focus on English-language publications.

Comparative Analysis: Where applicable, MIS techniques were compared with traditional open surgical methods. This comparative analysis provided a context for understanding the advancements and limitations of MIS.

Quality Assessment of Included Studies: The quality of included studies was assessed using standardized criteria, such as study design, sample size, and potential biases. This assessment helped in determining the reliability and validity of the findings presented in the review.

Development

Historical Evolution: The origins of minimally invasive surgery date back to the early 20th century with the advent of diagnostic laparoscopy. However, it wasn't until the late 1980s and early 1990s that MIS began to revolutionize surgical practice, starting with laparoscopic cholecystectomy. This period marked the beginning of a significant shift from traditional open surgeries to techniques aimed at reducing patient trauma and improving recovery times.^(3,5)

Technological Milestones: A pivotal aspect of the development of MIS has been the advancement in surgical technology. Key milestones include the introduction of high-definition video laparoscopes, the development of specialized instruments such as endoscopic scissors and graspers, and the advent of robotic surgical systems. Each of these technological advancements expanded the capabilities of surgeons and broadened the range of procedures that could be performed minimally invasively.^(2,5)

Expansion into Various Specialties: Initially limited to general surgery, the principles and techniques of MIS quickly spread to other specialties. In orthopedics, arthroscopic techniques revolutionized joint surgeries. In urology, laparoscopic and endoscopic methods transformed kidney and prostate surgeries. Similarly, in neurosurgery, techniques like endoscopic third ventriculostomy challenged traditional approaches.⁽⁶⁾

Integration of Robotics: the integration of robotic systems marked a new era in MIS. The precision and control offered by robotic platforms, such as the da Vinci Surgical System, allowed for even more complex procedures to be performed with enhanced accuracy and minimal invasiveness. Robotic systems also facilitated remote surgery capabilities, a significant step forward in surgical practice.^(7,8)

Advancements in Imaging and Navigation: concurrent with the development of surgical techniques were advancements in imaging and navigation technologies. Real-time imaging, 3D reconstruction, and computer-assisted navigation systems provided surgeons with unprecedented views of the surgical field, improving the accuracy and safety of procedures.⁽⁹⁾

Impact on Training and Skill Acquisition: the evolution of MIS necessitated a parallel evolution in surgical training. Traditional apprenticeship models were supplemented with simulation-based training, virtual reality environments, and specialized courses focusing on MIS techniques. This shift was crucial in preparing new generations of surgeons for the intricacies of MIS.^(10,11)

Challenges and Resolutions: the development of MIS was not without challenges. Initial resistance from the surgical community, concerns over patient safety, and the steep learning curve associated with new techniques were significant hurdles. Over time, extensive clinical studies, continuous refinement of techniques, and the development of standardized training programs helped in overcoming these challenges.⁽¹²⁾

Future Directions: As MIS continues to evolve, emerging technologies such as artificial intelligence, augmented reality, and nanotechnology are poised to further revolutionize this field. The potential for even less invasive procedures, personalized surgical approaches, and enhanced patient outcomes are areas of active research and development.⁽¹³⁾

Refinement and Specialization of Techniques: As minimally invasive surgical techniques matured, a trend towards specialization and refinement became evident. Surgeons began developing MIS approaches tailored to specific conditions and anatomical challenges. For example, in gastroenterology, the evolution of minimally invasive techniques for bariatric surgery significantly improved outcomes for patients with obesity. Similarly, advancements in minimally invasive thoracic surgery, such as video-assisted thoracoscopic surgery (VATS), offered a less invasive alternative for lung and esophageal surgeries. These specialized techniques required surgeons to develop a deep understanding of specific anatomical areas and pathologies, marking a shift from generalist to more specialized MIS practices.⁽¹⁴⁾

Enhanced Patient Recovery Programs: The development of Enhanced Recovery After Surgery (ERAS) programs represented a significant shift in postoperative care. These programs, tailored to complement MIS techniques, focused on reducing the stress of surgery and promoting a faster recovery. Key elements included minimizing the use of narcotics, encouraging early mobilization, and optimizing nutrition. The implementation of ERAS programs in conjunction with MIS techniques led to reduced hospital stays, decreased complications, and improved patient satisfaction.^(15,16)

Global Spread and Standardization: As the benefits of MIS became more apparent, these techniques gained global traction. However, this global spread also highlighted disparities in access to MIS across different regions. Efforts were made to standardize MIS training and practices to ensure more uniform adoption and adaptation of these techniques worldwide. International collaborations, workshops, and tele-mentoring programs were established to bridge the knowledge gap, particularly in low- and middle-income countries.⁽¹⁷⁾

Economic Impact and Healthcare System Integration: The integration of MIS techniques had a significant economic impact on healthcare systems. Initially, the high cost of equipment and training was a barrier to widespread adoption. However, over time, the long-term cost-effectiveness of MIS, due to factors like shorter hospital stays and lower complication rates, became apparent. Healthcare systems began to integrate MIS not only as a clinical choice but also as a strategic approach to improve efficiency and patient throughput.^(4,18)

Advancements in Pain Management and Anesthesiology: The development of MIS also drove innovations in pain management and anesthesiology. New anesthesia techniques, such as regional blocks and the use of multimodal pain management strategies, were developed to complement MIS procedures. These advancements allowed for better pain control, reduced reliance on opioids, and contributed to quicker patient recovery and discharge.^(19,20)

Patient Safety and Quality Improvement Initiatives: With the increasing complexity of MIS procedures, patient safety and quality improvement became paramount. Initiatives such as the Surgical Care Improvement Project (SCIP) and the development of MIS-specific safety guidelines aimed to standardize practices and reduce surgical complications. The focus on quality improvement also led to the implementation of regular audits, outcome tracking, and the establishment of centers of excellence for MIS procedures.^(21,22)

The Role of Research and Continuous Innovation: Continuous research and innovation have been central to the development of MIS. Multidisciplinary research teams, including surgeons, engineers, and computer scientists, continue to push the boundaries of what is possible in MIS. The ongoing development of new materials, surgical instruments, and imaging techniques promises to further enhance the capabilities and scope of MIS in the future.⁽²³⁾

Table 1. Summary of Key Findings in Minimally Invasive Surgical Techniques
Category	Advancements/Findings	Impact/Efficacy	Future Prospects
Technological Innovations	Development of high-definition laparoscopes, robotic surgical systems, advanced endoscopic tools.	Increased precision and safety in surgeries, reduced complication rates.	Continued enhancement of robotic capabilities, integration of AI and machine learning.
Specialized MIS Procedures	Refinement of techniques in bariatric, thoracic, and orthopedic surgeries.	Improved patient-specific outcomes, higher success rates in complex procedures.	Development of more specialized tools and techniques for niche applications.
Training and Education	Implementation of simulation-based training, virtual reality programs.	Improved surgeon proficiency, adaptation to MIS techniques.	Expansion of training programs, integration of real-time learning and feedback systems.
Patient-Centered Outcomes	Enhanced Recovery After Surgery (ERAS) programs, improved pain management strategies.	Shorter hospital stays, increased patient satisfaction, quicker recovery.	Further personalization of recovery programs, use of patient data analytics.
Global Accessibility	Standardization of training, international collaborations, and workshops.	More uniform adoption of MIS techniques, reduced disparities in surgical care.	Expansion of tele-mentoring, development of low-cost MIS solutions for resource-limited settings.
Economic and Healthcare Impact	Long-term cost-effectiveness analysis, integration into healthcare systems.	Reduction in overall healthcare costs, improved efficiency and patient throughput.	Strategic planning in healthcare systems for broader MIS integration.
Safety and Quality Initiatives	Development of MIS-specific safety guidelines, implementation of quality improvement projects.	Standardization of practices, reduction in surgical complications.	Ongoing monitoring and refinement of safety protocols, establishment of new guidelines as techniques evolve.

Table 2. Comparative Analysis of Traditional Open Surgery and Minimally Invasive Surgery (MIS)
Parameter	Traditional Open Surgery	Minimally Invasive Surgery	Notes/Observations
Incision Size	Large incisions for access	Small incisions, often less than a few centimeters	MIS results in reduced scarring and post-operative pain.
Intraoperative Visualization	Direct visualization of the surgical field	Indirect visualization through cameras and imaging technology	MIS utilizes advanced imaging techniques for enhanced visibility.
Blood Loss	Typically, higher due to larger incisions	Reduced blood loss owing to smaller incisions and precise techniques	Less blood loss in MIS can lead to faster recovery.
Postoperative Pain	Generally higher, requiring more pain medication	Typically, less pain due to smaller incisions and less tissue trauma	Reduced pain in MIS often leads to decreased reliance on pain medications.
Recovery Time	Longer hospital stays and recovery period	Shorter hospital stays, faster return to daily activities	The quick recovery in MIS is a significant advantage for patients.
Complication Rates	Variable, depending on the procedure and patient factors	Often lower, but dependent on surgeon skill and procedure complexity	MIS can lead to fewer complications like infections and hernias.
Cost	Varies, often higher due to longer hospitalization	Initial high cost due to equipment, but overall cost-effective in the long run	The economic advantage of MIS becomes more apparent in long-term analysis.
Surgical Precision	Dependent on surgeon's skill and technique	Enhanced by technological aids like robotics and navigation systems	MIS allows for higher precision, especially in complex areas.
Application Range	Broad, suitable for most surgical procedures	Expanding, initially limited but now applicable to many procedures	The range of MIS is continually growing with technological advancements.
Training and Skill Requirement	Traditional surgical training focused on open techniques	Requires specialized training in MIS techniques and equipment handling	Surgeons need to adapt to the evolving landscape of surgical training.

This table provides a comparative overview between traditional open surgery and minimally invasive surgery, highlighting the differences in various surgical aspects. The observations noted are generalized and may vary based on specific circumstances, procedure types, and individual patient factors.

Table 3. Prospects and Emerging Trends in Minimally Invasive Surgery
Emerging Trend/Prospect	Description/Features	Potential Impact on Surgery	Challenges/Considerations
Artificial Intelligence (AI) Integration	AI algorithms aiding in diagnostic processes, surgical planning, and intraoperative decision-making.	Increased precision and efficiency in surgeries, potential for personalized surgical plans.	Ensuring accuracy and reliability of AI systems, addressing ethical concerns.
Augmented Reality (AR) and Virtual Reality (VR)	Use of AR for real-time overlay of critical information during surgery; VR in training and simulation.	Enhanced surgical visualization and precision; improved training methods.	High development costs, ensuring real-world applicability.
Nanotechnology in Surgery	Development of nanorobots for targeted therapy, microsurgery, and diagnostics.	Minimally invasive procedures at a cellular or molecular level, potentially less trauma.	Technical challenges in development, ensuring safety and regulatory compliance.
Advanced Robotic Systems	Next-generation robotic systems with improved dexterity, haptic feedback, and autonomous capabilities.	Enhanced surgical precision, potential for remote surgeries, reduced surgeon fatigue.	High costs, maintaining surgeon skills and decision-making authority.
Personalized Surgical Approaches	Tailoring surgical techniques based on patient-specific data, genetics, and anatomy.	Improved outcomes and reduced complications, patient-specific treatment plans.	Need for extensive patient data, integrating into standard practice.
Minimally Invasive Cardiac Surgery	Advancements in techniques for cardiac procedures, such as valve replacements and bypass surgeries.	Reduced trauma and faster recovery for cardiac patients, broader applicability.	Specialized training and equipment, managing complex cardiac conditions.
Bioabsorbable Implants	Development of implants that dissolve or get absorbed by the body, eliminating the need for removal.	Reduced need for follow-up surgeries, improved patient comfort.	Ensuring long-term reliability and material safety.
Enhanced Recovery Protocols	Optimization of postoperative care plans, incorporating the latest in pain management and rehabilitation strategies.	Quicker recovery times, reduced hospital stays, and improved patient experiences.	Tailoring protocols to individual patient needs, continuous updating with new research.
Telesurgery and Remote Operations	Performing surgeries remotely using advanced communication networks and robotic systems.	Access to surgical expertise in remote locations, expanded global reach of MIS.	Dependence on reliable technology and networks, addressing legal and ethical considerations.
3D Printing in Surgical Applications	Custom 3D printed surgical tools and patient-specific anatomical models for preoperative planning.	Customized surgical equipment, improved pre-surgical planning and precision.	Managing costs, ensuring accuracy and material safety.

Table 3 presents an overview of the prospects and emerging trends in minimally invasive surgery, highlighting the potential impacts and challenges associated with each trend.

DISCUSSION

The exploration of MIS techniques, as presented in this review, underscores a significant paradigm shift in surgical practice. The discussion of various studies and expert opinions reveals a consistent trend towards reduced patient morbidity, improved recovery times, and enhanced surgical precision, echoing the primary goals of MIS.

The integration of robotic systems in MIS, as highlighted in recent research, has been a game-changer, particularly in procedures requiring high precision. These studies show how robotic assistance has not only enhanced surgical accuracy but also enabled surgeries that were previously not feasible through minimally invasive methods. Despite these advancements, the discussion around the cost-effectiveness of robotic systems remains complex, with some analyses suggesting that the high initial investment may be offset by long-term benefits such as reduced complication rates and shorter hospital stays.^(7,13)

Advancements in imaging and navigation technologies, as discussed in several key articles, have played a crucial role in the advancement of MIS. Enhanced real-time imaging has allowed for more accurate and safer surgical interventions, as evidenced by a lower rate of intraoperative complications in procedures utilizing these technologies.⁽⁹⁾

The impact of MIS on surgical training and education is another critical area of discussion. The shift from traditional open surgery techniques to MIS requires a rethinking of surgical education curricula, as indicated by multiple studies focusing on training methods. Simulation-based training and virtual reality have emerged as essential tools in this transition, helping surgeons acquire the necessary skills for MIS in a risk-free environment.⁽²⁴⁾

Despite the numerous advantages of MIS, challenges such as the steep learning curve for surgeons and the need for continuous skill development are prominent in the literature. Furthermore, the review highlights ethical and socioeconomic considerations, such as disparities in access to MIS across different regions and healthcare systems. These discussions are crucial in understanding the broader implications of adopting MIS globally.

CONCLUSIONS

The comprehensive review of advancements in MIS techniques demonstrates a significant evolution in surgical practice, marked by enhanced patient outcomes, reduced recovery times, and increased surgical precision. Although challenged by factors like the steep learning curve for surgeons and disparities in global access, the integration of cutting-edge technologies such as robotics, advanced imaging, and simulation training continues to propel MIS forward. As the field advances, ongoing research, ethical considerations, and adaptation in surgical education remain crucial for harnessing the full potential of MIS in improving patient care. This review underscores the transformative impact of MIS on healthcare, highlighting it as a key driver in the future landscape of surgical interventions.

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Financing

No external financing.

Conflict of interest

The authors declare that there are no conflicts of interest.

Authorship contribution

Conceptualization: Andrea Patricia Pérez Ayme, Josseline María Caiza Suárez, Martin Mateo Paredes Ortega, Daniel Samuel Gualoto Gualoto, Juan Carlos Santillán Lima, Adriana Elizabeth Rivera Campoverde, Alfredo Augusto Rivera Ticona, Jonathan Steven Coello Vergara, Gerzon David Martínez Serrano.

Investigation: Andrea Patricia Pérez Ayme, Josseline María Caiza Suárez, Martin Mateo Paredes Ortega, Daniel Samuel Gualoto Gualoto, Juan Carlos Santillán Lima, Adriana Elizabeth Rivera Campoverde, Alfredo Augusto Rivera Ticona, Jonathan Steven Coello Vergara, Gerzon David Martínez Serrano.

Methodology: Andrea Patricia Pérez Ayme, Josseline María Caiza Suárez, Martin Mateo Paredes Ortega, Daniel Samuel Gualoto Gualoto, Juan Carlos Santillán Lima, Adriana Elizabeth Rivera Campoverde, Alfredo Augusto Rivera Ticona, Jonathan Steven Coello Vergara, Gerzon David Martínez Serrano.

Writing - original draft: Andrea Patricia Pérez Ayme, Josseline María Caiza Suárez, Martin Mateo Paredes Ortega, Daniel Samuel Gualoto Gualoto, Juan Carlos Santillán Lima, Adriana Elizabeth Rivera Campoverde, Alfredo Augusto Rivera Ticona, Jonathan Steven Coello Vergara, Gerzon David Martínez Serrano.

Writing - review and editing: Andrea Patricia Pérez Ayme, Josseline María Caiza Suárez, Martin Mateo Paredes Ortega, Daniel Samuel Gualoto Gualoto, Juan Carlos Santillán Lima, Adriana Elizabeth Rivera Campoverde, Alfredo Augusto Rivera Ticona, Jonathan Steven Coello Vergara, Gerzon David Martínez Serrano.