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The needle-based procedures are usually considered minimally invasive. However, in insertion into soft tissues such as brain and liver, the tissue damage caused by needle insertion can be very significant. From the literature, it has been known that reduction in needle insertion and extraction forces as well as tissue deformation during the insertion results in less invasive procedure. This work aims to design and develop a new bioinspired design for surgical needles which reduce the insertion and extraction forces of the needle, and its damage to the tissue. Barbs in honeybee stinger decrease its insertion force significantly. Inspired by that finding, a new honeybee-inspired needle was designed and developed, and its insertion mechanics was studied. To study the insertion mechanics of honeybee-inspired needle, insertion tests into artificial and biological tissues were performed using both honeybee-inspired and conventional needles. The barb design parameters effects on needle forces were studied through multiple insertion and extraction tests into PVC gels. The design parameters values of the barbs were experimentally modified to further reduce the ultimate insertion and extraction forces of the needle. Bioinspired needle with modified barb design parameters values reduces the insertion force by 35%, and the extraction force by 20%. To show the relevance, the insertion tests into bovine liver and brain tissue were performed. Our results show that there was a 10-25% decrease in the insertion force for insertions into bovine brain, and a 35-45% reduction in the insertion force for insertions into the bovine liver using the proposed bioinspired needles. The bioinspired and conventional needles were manufactured in different scales and then used to study the size scale effect on our results. To do so, the insertion tests into tissue-mimicking PVC gels and liver tissues were performed. The results obtained for different sizes of the needle showed 25-46% decrease in the insertion force. The tissue deformations study was conducted to measure tissue deformation during the insertion using digital image correlation. The tissue deformation results showed 17% decrease in tissue deformation using barbed needles. A histological study was performed to accurately measure the damage caused by needle insertion. Our results showed 33% less tissue damage using bioinspired needles. The results of the histological study are in agreement with our hypothesis that reducing needle forces and tissue deformation lead to less invasive percutaneous procedures. / Mechanical Engineering

Malignant gliomas (MG), most notably glioblastoma multiforme (GBM), are among the most aggressive of all malignancies. High-grade variants of this type of brain cancer are generally considered incurable with singular or multimodal therapies. Many patients with GBM die within one year of diagnosis, and the 5-year survival rate in people is approximately 10%. Despite extensive research in diagnostic and therapeutic technologies, very few developments have emerged that significantly improve survival over the last seven decades. Irreversible electroporation (IRE) is a new non-thermal focal tissue ablation technique that uses low-energy electric pulses to destabilize cell membranes, thus achieving tissue death. The procedure is minimally invasive and is performed through small electrodes inserted into the tissue with treatment duration of about one minute. The pulses create an electric field that induces an increase in the resting transmembrane potential (TMP) of the cells in the tissue. The induced increase in the TMP is dependent on the electric pulse parameters. Depending on the magnitude of the induced TMP the electric pulses can have no effect, transiently increase membrane permeability or cause spontaneous death. In this dissertation we hypothesize that irreversible electroporation is capable of ablating normal (gray and white matter) and pathological (MG and/or GBM) brain tissue in a highly focused non-thermal manner that is modulated through pulse parameters and electrode configuration. Through a comprehensive experimental and numerical investigation, we tested and attained results strongly supporting our hypothesis. Specifically, we developed numerical models that were capable of simulating an entire IRE treatment protocol and would take into account pulse parameters (e.g. duration, frequency, repetition rate and strength) in addition to the dynamic changes in tissue electrical conductivity due to electroporation and joule heating, as well as biologically relevant processes such as blood perfusion and metabolic heat. We also provided a method to isolate the IRE effects from undesired thermal damage in models that were validated with real-time temperature measurements during the delivery of the pulses. Finally we outlined a procedure to use 3D volumetric reconstructions of IRE lesions using patient specific MRI scans in conjunction with the models described for establishing field thresholds or performing treatment planning prior to the surgical procedure; thus supplying the readers with the tools and understanding necessary to design appropriate treatment protocols for their specific application. Experimentally we presented the first systematic in vivo study of IRE in normal canine brain and the multimodal treatment of a canine MG patient. We confirmed that the procedure can be applied safely in the brain and was well tolerated clinically. The lesions created with IRE were sub-millimeter in resolution and we achieved 75% tumor volume reduction within 3 days post-IRE in the patient. In addition to the sharp delineation between necrotic and normal brain, the treatments spared the major blood vessels, making it appropriate for treatment of tumors adjacent to, or enveloping critical vascular structures. We believe that irreversible electroporation will play a key role in the treatment of intracranial disorders including malignant brain cancer in which the intent is to focally kill undesired tissue while minimizing damage to surrounding healthy tissue. / Ph. D.

The objective of this prospective pilot study is to assess the feasibility of a minimally invasive, integrated endoscopic hemilaminectomy in chondrodystrophic dogs with clinically relevant Hansen type 1 intervertebral disc extrusion (IVDE). Study subjects included five client-owned chondrodystrophic dogs under 15kg with an acute, single site IVDE between T10 and L5 of less than 90 days duration and no loss of deep pain perception. The extent of the extrusion could not exceed 2/3 the diameter of the cannula to be used as defined by magnetic resonance imaging (MRI). A postoperative MRI was performed to assess remaining spinal cord compression. If significant compression remained, patients returned to surgery for a standard, open hemilaminectomy. Only the first dog required conversion to an open approach which resulted in adequate decompression. The same dog had a significant surgical complication of iatrogenic damage to the spinal cord during the minimally invasive approach. The other 4 dogs had no complications and achieved adequate spinal cord decompression. Three dogs eventually returned to normal neurologic status and another was improved compared to presentation. One dog was euthanized for reasons unrelated to IVDE. The authors conclude that a minimally invasive, integrated endoscopic hemilaminectomy is a feasible approach and can allow for adequate decompression of the spinal cord secondary to acute, single-site extrusion. Endoscopic approaches have a steep learning curve and extra care is required in the learning phase to avoid complications. Further studies are warranted to compare the safety and efficacy of this technique to a standard approach. / Master of Science / Acute intervertebral disc extrusion, or "slipped disc", is a common spinal emergency in dogs, particularly in small, chondrodystrophic breeds like dachshunds. Surgery is aimed at removing the disc material causing spinal cord compression. The traditional approach, known as a hemilaminectomy, involves elevating the muscles along the spine over multiple vertebrae, followed by creating a window in the bone with a surgical burr. Minimally invasive spinal surgery that minimizes the elevation of muscles, has the potential to decrease postoperative pain, surgical time, hospital stay, intraoperative blood loss and recovery time. This study was designed to assess the use of a minimally invasive, integrated endoscopic approach to a hemilaminectomy in clinical patients. Five dogs were enrolled with an acute, single site intervertebral disc extrusion between T10 and L5 that was no more than 2/3 the diameter of the cannula to be used in surgery. Study subjects were chondrodystrophic breeds under 15kg. All dogs had intact deep pain perception. Spinal cord compression was assessed by magnetic resonance imaging (MRI) both before and after a minimally invasive approach. If significant acute compression remained, a standard, open approach was immediately performed. Spinal cord decompression was adequate in all but one dog which required a second procedure to remove the remaining material. This same dog had accidental damage to the spinal cord during the minimally invasive approach. Three dogs eventually returned to normal neurologic status and the dog that required a second, traditional approach surgery eventually improved compared to his preoperative status. One dog was improving but euthanized eight days later due to chronic disease unrelated to IVDE. This approach is feasible for decompressing the spinal cord after a single site, acute intervertebral disc extrusion in a chondrodystrophic dog. However, like any endoscopic surgery, previous experience is of great benefit and errors are more likely to happen during the learning phase.

1. Bibliometric study in pediatric minimally invasive surgery (MIS) Pediatric MIS is a standard technique worldwide for many pediatric surgical diseases and we aimed to analyze the research activity in this field. Articles on pediatric MIS (1991–2020) were analyzed from the Web of ScienceTM for the total number of publications, citations, journals, and IFs. Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). 2. Altmetric study in pediatric surgery Altmetric analysis assessing online mentions of publications is a new method to evaluate awareness to research output. We aimed to identify and characterize the top 100 articles with the highest Altmetric Attention Score (AAS) in pediatric surgery. Publications from core pediatric surgical journals (J Pediatr Surg, J Pediatr Surg Case Rep, Eur J Pediatr Surg, European J Pediatr Surg Rep, Pediatr Surg Int, Semin Pediatr Surg) were retrieved from www.altmetric.com in January 2023 and the top 100 publications were identified. Characteristics of each publication were analyzed. Publications ranked 93 to 101 had an identical AAS of 21. Thus, 101 articles were included for further analysis. The top 101 AAS articles were published between 1974 and 2022, preferentially from the United States (64%) and mainly in J Pediatr Surg (73%), followed by J Pediatr Surg Case Rep, Pediatr Surg Int, Semin Pediatr Surg, and Eur J Pediatr Surg. Their AAS ranged between 21 and 389 (median 33) with X (formerly Twitter) being mostly responsible for online mentions (n=2189, 75%). The number of citations ranged from 0 to 358 (median 16) and did not correlate with the AAS. Retrospective study design (33%) with low evidence level IV (49%) was the dominant study type. 3. Conclusions According to our bibliometric study in pediatric MIS, research activity increased over the last 30 years, with a golden decade in the early 21st century. Laparoscopic pyeloplasty and inguinal hernia repair accounted for most of the top 50 citations. Retrospective studies and case reports were the most common type of publication. Studies with high level of evidence such as randomized controlled trials are missing, especially on advanced techniques in pediatric MIS. For our altmetric study of publications in core pediatric surgery journals, we analyzed the top 101 most mentioned pediatric surgery articles in six pediatric journals. Among the pediatric surgical journals, the Journal of Pediatric Surgery is the main source for high-profile publications in pediatric surgery. The altmetric score of articles is predominantly achieved by their propagation via X (formerly Twitter), irrespective of study design, level of evidence or recognition by the scientific community. Therefore, active “twitterism” may play the key role in reaching high AAS.

Thesis (MScEng)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Minimally Invasive Surgery (MIS) in human beings is performed by making small incisions in the abdominal region of the patient and inflating the abdominal cavity with CO2. This procedure enables the surgeon to manipulate long rigid surgical instruments inside the patient in order to perform the surgery. Unfortunately the current methods of insertion and assembly of MIS instruments limit the surgeon to only five (of a possible seven) Degrees of Freedom (DOF). Along with this, the surgeon’s movements are mirrored (called the Fulcrum effect) and scaled around the point of incision. Minimally invasive surgical robots attempt to alleviate these drawbacks by eliminating the Fulcrum effect, as well as improving dexterity and accuracy. These robots’ abilities to improve the surgeon’s hand-eye coordination, enables the surgeon to perform surgeries using their natural movements with reduced fatigue. As a result of this, the risk to both patient and surgeon is reduced. Existing MIS robotic systems are extremely expensive and large, and as a result they are not widely used. In this thesis a new, lower cost, seven DOF robotic manipulator is further developed. The thesis focuses on the external three DOF Secondary Slave Manipulator (SSM) and combines it with the Primary Slave Manipulator (PSM) that was developed by a previous Masters student. Tests done on the SSM showed that the manipulator has a minimum resolution of 0.7 ± 0.2 mm (mean ± standard deviation) on the shoulder joint’s yaw rotation and 0.5 ± 0.2 mm in pitch rotation. The linear actuator used for insertion has a minimum resolution of 0.2 ± 0.2 mm. A strength test was also conducted and showed that the manipulator is easily capable of producing a 10 N actuation force as required during Minimally Invasive Robotic Surgery (MIRS) procedures. In conclusion the complete system has potential as a viable alternative to the existing systems due to its accuracy and lower cost. Future work will include the development of a user interface and control system for the complete robot. / AFRIKAANSE OPSOMMING: Minimaal Indringende Chirurgie (MIC) op mense word uitgevoer deur klein insnydings in die pasiënt se buik te maak en dan die abdominale holte met CO2 te vul. Dit stel die chirurg in staat om lang, onbuigbare instrumente binne die pasiënt te manipuleer om sodoende die operasie uit te voer. Die manier waarop die MIC instrument ontwerp is en die pasiënt binnegaan, laat egter slegs vyf vryheidsgrade toe, terwyl die chirurg self sewe vryheidsgrade in sy handbewegings het. Verder veroorsaak hierdie instrumente ook dat die chirurg se aksies in spieëlbeeld vertolk word (Fulcrum effek) en geskaleer is. Chirurgiese robotika poog om hierdie nadele teen te werk deur die Fulcrum effek te verwyder, en ook om handvaardigheid en akkuraatheid te bevorder. Die robot se potensiaal om die chirurg se hand-oog koӧrdinasie te verbeter, maak dit moontlik vir die chirurg om op ’n meer natuurlike en gemaklike manier te werk te gaan en bring minder vermoeienis mee. Dit verminder die risiko’s vir beide die pasiënt en die chirurg. Bestaande robotiese stelsels is egter baie duur en groot, en word dus nie meer algemeen gebruik nie. In hierdie tesis word ‘n nuwe sewe-vryheidsgraad robotiese manipuleerder ontwikkel. Die tesis fokus op die eksterne drie-vryheidsgraad Sekondêre Slaaf Manipuleerder (SSM) en kombineer dit met die Primêre Slaaf Manipuleerder (PSM) wat deur ʼn vorige Meestersstudent ontwikkel is. Toetse wat uitgevoer is op die SSM het getoon dat dit ’n minimum resolusie van 0.7 ± 0.2 mm (gemiddeld ± standaard afwyking) op die skouer se afwyking en 0.5 ± 0.2 mm om die onderskeie skouer aslyne toon. Die linieêre aktueerder wat vir inlassing gebruik word het ’n minimum resolusie van 0.2 ± 0.2 mm. ’n Sterktetoets is uitgevoer en het getoon dat die manipuleerder maklik die nodige 10 N krag soos benodig in Minimaal Indringende Robotiese Chirurgie (MIRC) prosedures kan lewer. Ter afsluiting, die volledige stelsel het die potensiaal as lewensvatbare alternatief tot die bestaande stelsels vanweë die akkuraatheid en laer koste verbonde. Toekomstige navorsing kan moontlik die ontwikkeling van ʼn gebruikerkoppelvlak en beheerstelsel vir die volledige robot insluit.

Minimally Invasive Surgery (MIS) differs from Open Surgery as surgeons view the surgical site indirectly on a monitor. The view shown is typically from an angled endoscope off to one side of the surgery (i.e., uncollocated with the view of the hands). This makes camera navigation a challenging ability to learn. MIS thus requires longer training periods, more practice and mental effort to achieve proficiency. Current training setups and Operating Room (OR) environments lack appropriate real-time visual cues for navigation and other perception related information that could help with learning and performance in the OR. The purpose of this research was to design and develop graphical aids for improving understanding of camera navigation and depth perception in a trainer box necessary for enhancing surgeon’s skills to perform endoscopic surgery. For the former, two alternate training methods: 1) using no graphics (control group) and 2) using three different types of graphics conveying different information, were considered for this study. The effectiveness of the training was evaluated by a comparative analysis of different performance measures across all the groups. It was observed that training using graphics did improve the performance of participants in performing a minimally invasive surgery training task. For the latter, the use of a proximity sensor was explored.

The purpose of this experiment was to determine if there existed techniques to more efficiently train prospective surgeons the skills necessary to capably perform minimally invasive surgical procedures. Also, we wanted to know if trainees could be pushed to cognitively define a laparoscopic environment with a novel hand-eye relationship. To explore these questions, a simulation was setup wherein subjects would perform a laparoscopic transfer task and receive active feedback during training. Different subjects would receive different metrics as feedback and a comparison would be made between subjects with respect to standard metrics. Results of this experiment show that all subjects adapt to a laparoscopic environment and that they do so at different rates and to different proficiencies. The difference was shown to be statistically significant. It was concluded that the techniques we utilized were effective enough to claim as useful techniques to utilize in current training systems.

Die pyogene Spondylodiszitis als bakterielle Osteomyelitis der Wirbelsäule ist eine seltene Entität der bakteriell-entzündlichen Pathologien des Stütz- und Bewegungsapparates. Trotz adäquater Behandlungsstrategien, wird auch heute noch eine Mortalitätsrate von 5% bis 20% beschrieben. Vor allem die in dem vorwiegend älteren Patientenkollektiv deutlich erhöhte Prävalenz an metabolischen oder kardiopulmonalen Komorbiditäten fordert moderne Therapiekonzepte, die eine risikoarme, jedoch effektive Eradifizierung des bakteriell-entzündlichen Fokus mit schneller Wiederherstellung der prämorbiden Mobilität ermöglichen. Ausgehend von zwei grundlagenwissenschaftlichen Studien, wurden in der vorliegenden Habilitationsschrift zunächst die komplexen Zusammenhänge von lokaler Gewebsveränderungen und systemischer Entzündung erörtert. Hierbei zeigten die Analysen humaner degenerativer und traumatischer Bandscheibenzellen, dass die Apoptose, insbesondere die Herabregulation anti-apoptotischer Schlüsselkomponenten wie das Bcl-2, als mögliche Schnittstelle im katabolen Stoffwechsel der extrazellulären Bandscheibenmatrix diskutiert werden kann. In der generalisierten bakteriellen Entzündung (Sepsis), ließ sich durch die gentherapeutisch gewebsständige Überexpression von antiapoptotischen und antiinflammatorischen Interleukin-10 (IL-10), auch im IL-10-defzienten Organismus, eine deutliche Reduktion der systemischen proinflammatorischen Immunantwort mit verbesserter Überlebensrate septischer Tiere erzielen. Jedoch birgt der substantielle Gewebeschaden bei pyogener Spondylodiszitis nicht selten die Gefahr der konsekutiven Instabilität mit neurologischen Komplikationen und stellt damit eine besondere chirurgische Herausforderung dar. Daher wurden in drei weiteren klinischen Studien unsere, in den letzten 10 Jahren etablierten, lösungsorientierten Strategien erläutert. Zur Überbrückung größerer knöcherner Defekte gelang mit der Implantation expandierbarer Titancages eine sichere knöcherne Durchbauung mit vollständiger Ausheilung des Infektes. Im Beobachtungszeitraum von mehr als 3 Jahren war bei keinem der Patienten ein Infektrezidiv zu verzeichnen. In komplexen Fällen von monosegmentaler Spondylodiszitis der LWS mit multisegmentaler epiduraler Abszedierung, führte die epidurale Katheterspülung über den dorsalen Zugang für die Spondylodese zu einer folgenlosen Ausheilung. Damit konnte ein zusätzliches, iatrogenes Trauma mit multisegmentalen Lamintomien über die Distanz des epiduralen Abszesses vermieden werden. In einer weiteren Studie mit einem Beobachtungszeitraum von bis zu 5 Jahren, erzielte die Implantation von Poly-Ether-Ether-Keton (PEEK) Cages zur dorsalen intersomatischen Fusion bei pyogener Spondylodiszitis eine sehr gute, stabile knöcherne Durchbauung des infizierten Segmentes, ebenfalls ohne Infektrezidiv. Diese Abweichung vom herkömmlichen Standard mit Titanimplantaten erwies sich somit als sichere Alternative mit den für PEEK charakteristischen, verbesserten Eigenschaften. Im Vergleich zu herkömmlichen Operationsverfahren, verspricht die Integration dieser Ergebnisse in die Weiterentwicklung minimal-invasiver Techniken, insbesondere im multimorbiden Patientenklientel, mindestens gleichwertig gute Ergebnisse bei deutlich reduziertem Operationstrauma.