Hintergrund: Die Simulation wichtiger Handgriffe und Techniken in der Chirurgie wurde bereits seit der Antike praktiziert. Pflanzen, Menschen- und Tierkadaver, Puppen sowie Phantome haben seit Jahrhunderten diesem Zweck gedient. Das 21. Jahrhundert ist jedoch von virtueller Realität geprägt und es gibt viele technische Neuerungen in der Chirurgie. Erste virtuelle Simulationsmöglichkeiten tauchten auf dem Markt bereits im 20. Jahrhundert auf. Zuerst nur schwarzweiß, rudimentär und nur andeutungsweise einer echten Situation im OP-Saal ähnlich, überzeugen die heutigen Simulatoren durch schnelle Prozessoren, qualitative graphische Darstellung und haptisches Feedback. Der Simulator selbst wird zum Forschungsobjekt, endlich können in Simulationsbedingungen Fragestellungen untersucht werden, die bisher unter Operationsbedingungen weder ethisch vertretbar noch technisch möglich waren. Fragestellung: Zwischen 2016 und 2017 fand am VTG Klinikum des Universitätsklinikums der TU Dresden Carl Gustav Carus eine Studie am chirurgischen Simulator für virtuelle Realität statt. Die untersuchte Fragestellung war die Übertragbarkeit von Fertigkeiten zwischen zwei laparoskopischen Operationen: Appendektomie und Cholezystektomie. Material und Methode: Es wurden 44 Studierende aus dem 3. bis 6. Studienjahr rekrutiert und in zwei Gruppen rand-omisiert. Beide Gruppen übten zunächst die Basisübungen bis bestimmte Leistungskriterien erfüllt wurden. Danach haben Probanden der ersten Gruppe die virtuelle Appendektomie und im Anschluss die virtuelle Cholezystektomie trainiert. Die zweite Gruppe ging sofort zum Cholezystektomie Training über. In beiden Gruppen wurden zum Schluss jeweils drei Wiederholungen der kompletten Cholezystektomie absolviert. Verglichen wurden Geschwindigkeit, Sicherheitsparameter wie z. B. aufgetretene Komplikationen sowie Motorik-Parameter der Instrumente. Des Weiteren wurde der mögliche Einfluss von Schlafverhalten, Koffeinkonsum und Erfahrung mit Videospielen auf die Leistung am Simulator untersucht. Ergebnisse: In der statistischen Analyse zeigte die erste Gruppe eine signifikante Verbesserung der Moto-rik-Parameter wie Instrumentenbewegungen und -strecke. Andere Werte wie Geschwindigkeit und Sicherheitsparameter waren innerhalb der zwei Gruppen ähnlich. Zwischen Schlaf-verhalten, Koffeinkonsum und Erfahrung mit Videospielen und der Leistung am Simulator konnte kein Zusammenhang festgestellt werden. Schlussfolgerungen: Die Studie ergab nur einen partiellen Übertragungseffekt zwischen laparoskopischer Appendektomie und Cholezystektomie. Die Gründe liegen in den jeweils unterschiedlichen Schlüsselmomenten, die die Beherrschung prozedurspezifischer Techniken erfordern. Diese müssen für jede Prozedur separat geübt werden. Die Verbesserung der feinmotorischen Fähigkeiten spricht jedoch dafür, dass eine Übertragung der Fertigkeiten bis zu einem gewissen Grad dennoch stattfand und durch das Trainieren einer zusätzlichen Modalität Vorteile insbesondere in der Bewegungsökonomie gewonnen werden können.:Inhaltsverzeichnis 3 Abkürzungsverzeichnis 7 1. Einleitung 8 1.1 Einblick in die Geschichte der chirurgischen Simulation 8 1.2 Entwicklung chirurgischer Simulatoren 9 1.3 Einsatz der Laparoskopie-Simulatoren in der heutigen chirurgischen Ausbildung 11 1.4 Übertragbarkeit von Fähigkeiten in der minimal invasiven Chirurgie 13 1.5 Laparoskopische Appendektomie und Cholezystektomie 17 1.5.1 Laparoskopische Appendektomie 17 1.5.2 Laparoskopische Cholezystektomie 18 1.6 Sonstige Aspekte des Trainings 19 1.6.1 Kriterien-basiertes Training 19 1.6.2 Betreuerfeedback 19 1.6.3 Leistung unter Beobachtung 20 1.6.4 Leistung unter Simulationsbedingungen 20 1.6.5.1 Schlafdauer 20 1.6.5.2 Kaffeekonsum 21 1.6.5.3 Motivation 21 1.6.5.4 Erfahrung mit Videospielen 22 2. Materialen und Methoden 23 2.1 Fragestellung 23 2.2 Ablauf der MIC Studie 24 2.3. Probandenrekrutierung 25 2.4 Lap Mentor von Simbionix (3D Systems) 27 2.5 Trainingsprotokolle am VRT-Simulator 28 2.5.1 Organisatorische Aspekte 28 2.5.2 Leistungsfeedback am VRT-Simulator 28 2.5.3 Training der Basis-Fertigkeiten (Basic Skills Training) 29 2.5.3.1 Peg Transfer 31 2.5.3.2 Clipping and Grasping 32 2.5.3.3 Electrocautery 33 2.5.3.4 Cutting 34 2.5.3.5 Pattern Cutting: Training Gauze 35 2.5.4 Training der Appendektomie Prozedur 36 2.5.5 Training der Cholezystektomie Prozedur 39 2.5.6 Subjektiver Schwierigkeitsgrad 43 2.6 Statistische Auswertung 44 3. Ergebnisse 45 3.1. Zusammenfassung der Probandencharakteristiken 45 3.2 Alter und Geschlecht der Probanden 45 3.3 Fragebogen 46 3.3.1 Schlaf 46 3.3.2 Kaffeekonsum 48 3.3.3 Motivation 49 3.3.4 Erfahrung mit Videospielen 50 3.3.5 Einflussfaktoren auf das Basistraining 50 3.4 Allgemeine Ergebnisse des Trainings am VRT Simulator 51 3.5 Ergebnisse des Trainings der Basis-Fertigkeiten 52 3.5.1 Peg Transfer 52 3.5.2 Clipping and Grasping 53 3.5.3 Electrocautery 54 3.5.4 Cutting 55 3.5.5 Pattern Cutting (Test Gauze) 56 3.5.6 Subjektiver Schwierigkeitsgrad für die Basis-Übungen 57 3.5.7. Zeitbedarf für das Erreichen der Könner-Kriterien 59 3.6 Ergebnisse des Appendektomie Trainings 60 3.7 Ergebnisse der Cholezystektomie Komplettprozedur 61 3.7.1 Geschwindigkeit 61 3.7.2 Sicherheitskriterien 62 3.7.2.1 Anzahl lebensbedrohlicher Komplikationen 62 3.7.2.2 Sichere Kauterisation 63 3.7.2.3 Anzahl verlorener Clips 63 3.7.2.4 Anzahl der Leberperforationen 64 3.7.2.5 Anzahl nicht kauterisierter Blutungen 64 3.7.3 Effizienz Kriterien 64 3.7.3.1 Anzahl der Instrumentenbewegungen 64 3.7.3.2 Gesamtstrecke der Instrumente 65 3.7.4 Subjektiver Schwierigkeitsgrad für die Cholezystektomie 65 3.7.5 Zeit für Basis Training und Cholezystektomie Parameter 65 4. Diskussion 67 4.1 Der Begriff des Übertragungsphänomens in Sportwissenschaften und seine Anwendbarkeit auf die laparoskopischen Fertigkeiten 67 4.2 Übertragbarkeit von Fertigkeiten zwischen virtueller Appendektomie und Cholezystektomie und Vergleich mit anderen Studien 74 4.3 Exploration zweitrangiger Fragestellungen 78 4.4 Vergleich zentraler Tendenzen der Cholezystektomie-Parameter mit Hersteller-Kriterien und externen Studien 79 4.5 Schlussfolgerungen aus dem Training der Basis-Fertigkeiten 81 4.6 Schlussfolgerungen aus dem Appendektomie Training 82 4.7 Schlussfolgerungen aus dem Cholezystektomie Training 83 4.8 Empfehlungen für das Ausbildungscurriculum an einem VR Simulator 85 4.9 Vorschlag für das Anfängertraining an einem VRT Simulator 91 4.10 Limitierungen der Arbeit 92 4.11 Ausblick 93 5. Zusammenfassung 94 5.1 Summary 96 6. Literatur 98 6.1 Abbildungsverzeichnis 106 6.2 Tabellenverzeichnis 108 7. Anhang 109 7.1 Probandenrandomisierung 109 7.2 Probandeninformationsblatt 110 7.3 Einwilligungserklärung 112 7.4 Beispiel Teilnahmebescheinigung 114 7.5 Zusammenfassung der aufgetretenen Softwarefehler am Lap Mentor II 115 8. Danksagung 116 9. Eigenständigkeitserklärung 117 Anlage 1 118 Anlage 2 120 / Background: Simulation of important surgical procedures and techniques has been practiced since ancient times. Plants, human and animal cadavers, dolls and phantoms have served this purpose for hundreds of years. However, the 21st century is characterized by virtual reality and there are also many technical innovations in the field of surgery. The first virtual simulation possibilities appeared on the market in the 20th century. Initially only black and white, rudimentary and only suggestively similar to a real situation in the operating room, today's simulators convince with fast processors, qualitative graphical representation and haptic feedback. The simulator itself becomes an object of research. At last, questions can be investigated in simulation conditions that were previously neither ethically nor technically possible under operating conditions. Hypothesis: Between 2016 and 2017, at the VTG clinic of the Carl Gustav Carus University Hospital of the TU Dresden a study using a surgical simulator for virtual reality took place. The question investigated was the transferability of skills between two laparoscopic procedures: appendectomy and cholecystectomy. Methods: 44 students from the 3rd to 6th year of study were recruited and randomly divided into two groups. Both groups initially practiced the basic exercises until certain criteria were met. Afterwards, the first group practiced virtual appendectomy and then virtual cholecystectomy. The second group immediately moved on to cholecystectomy training. In both groups, three repetitions of the complete cholecystectomy were completed in the end. Speed, safety parameters such as complications that occurred and efficiency parameters of the instruments were compared. Furthermore, the possible influence of sleep behavior, caffeine consumption and experience with video games on simulator performance was investigated. Results: In the statistical analysis, the first group showed a significant reduction in the efficiency parameters such as instrument movements and distance travelled. Other values like speed and safety parameters were similar within two groups. There was no correlation between sleep behavior, caffeine consumption and experience with video games and simulator performance. Conclusion: The study showed only a partial skill transfer between laparoscopic appendectomy and cholecystectomy. The reasons are the different key moments that require the mastery of procedure-specific techniques. These must be practiced separately for each procedure. However, the improvement of fine motor skills indicates, that by training an additional modality a skill transfer nevertheless took place to a certain degree and that advantages, especially in the economy of movement, were gained.:Inhaltsverzeichnis 3 Abkürzungsverzeichnis 7 1. Einleitung 8 1.1 Einblick in die Geschichte der chirurgischen Simulation 8 1.2 Entwicklung chirurgischer Simulatoren 9 1.3 Einsatz der Laparoskopie-Simulatoren in der heutigen chirurgischen Ausbildung 11 1.4 Übertragbarkeit von Fähigkeiten in der minimal invasiven Chirurgie 13 1.5 Laparoskopische Appendektomie und Cholezystektomie 17 1.5.1 Laparoskopische Appendektomie 17 1.5.2 Laparoskopische Cholezystektomie 18 1.6 Sonstige Aspekte des Trainings 19 1.6.1 Kriterien-basiertes Training 19 1.6.2 Betreuerfeedback 19 1.6.3 Leistung unter Beobachtung 20 1.6.4 Leistung unter Simulationsbedingungen 20 1.6.5.1 Schlafdauer 20 1.6.5.2 Kaffeekonsum 21 1.6.5.3 Motivation 21 1.6.5.4 Erfahrung mit Videospielen 22 2. Materialen und Methoden 23 2.1 Fragestellung 23 2.2 Ablauf der MIC Studie 24 2.3. Probandenrekrutierung 25 2.4 Lap Mentor von Simbionix (3D Systems) 27 2.5 Trainingsprotokolle am VRT-Simulator 28 2.5.1 Organisatorische Aspekte 28 2.5.2 Leistungsfeedback am VRT-Simulator 28 2.5.3 Training der Basis-Fertigkeiten (Basic Skills Training) 29 2.5.3.1 Peg Transfer 31 2.5.3.2 Clipping and Grasping 32 2.5.3.3 Electrocautery 33 2.5.3.4 Cutting 34 2.5.3.5 Pattern Cutting: Training Gauze 35 2.5.4 Training der Appendektomie Prozedur 36 2.5.5 Training der Cholezystektomie Prozedur 39 2.5.6 Subjektiver Schwierigkeitsgrad 43 2.6 Statistische Auswertung 44 3. Ergebnisse 45 3.1. Zusammenfassung der Probandencharakteristiken 45 3.2 Alter und Geschlecht der Probanden 45 3.3 Fragebogen 46 3.3.1 Schlaf 46 3.3.2 Kaffeekonsum 48 3.3.3 Motivation 49 3.3.4 Erfahrung mit Videospielen 50 3.3.5 Einflussfaktoren auf das Basistraining 50 3.4 Allgemeine Ergebnisse des Trainings am VRT Simulator 51 3.5 Ergebnisse des Trainings der Basis-Fertigkeiten 52 3.5.1 Peg Transfer 52 3.5.2 Clipping and Grasping 53 3.5.3 Electrocautery 54 3.5.4 Cutting 55 3.5.5 Pattern Cutting (Test Gauze) 56 3.5.6 Subjektiver Schwierigkeitsgrad für die Basis-Übungen 57 3.5.7. Zeitbedarf für das Erreichen der Könner-Kriterien 59 3.6 Ergebnisse des Appendektomie Trainings 60 3.7 Ergebnisse der Cholezystektomie Komplettprozedur 61 3.7.1 Geschwindigkeit 61 3.7.2 Sicherheitskriterien 62 3.7.2.1 Anzahl lebensbedrohlicher Komplikationen 62 3.7.2.2 Sichere Kauterisation 63 3.7.2.3 Anzahl verlorener Clips 63 3.7.2.4 Anzahl der Leberperforationen 64 3.7.2.5 Anzahl nicht kauterisierter Blutungen 64 3.7.3 Effizienz Kriterien 64 3.7.3.1 Anzahl der Instrumentenbewegungen 64 3.7.3.2 Gesamtstrecke der Instrumente 65 3.7.4 Subjektiver Schwierigkeitsgrad für die Cholezystektomie 65 3.7.5 Zeit für Basis Training und Cholezystektomie Parameter 65 4. Diskussion 67 4.1 Der Begriff des Übertragungsphänomens in Sportwissenschaften und seine Anwendbarkeit auf die laparoskopischen Fertigkeiten 67 4.2 Übertragbarkeit von Fertigkeiten zwischen virtueller Appendektomie und Cholezystektomie und Vergleich mit anderen Studien 74 4.3 Exploration zweitrangiger Fragestellungen 78 4.4 Vergleich zentraler Tendenzen der Cholezystektomie-Parameter mit Hersteller-Kriterien und externen Studien 79 4.5 Schlussfolgerungen aus dem Training der Basis-Fertigkeiten 81 4.6 Schlussfolgerungen aus dem Appendektomie Training 82 4.7 Schlussfolgerungen aus dem Cholezystektomie Training 83 4.8 Empfehlungen für das Ausbildungscurriculum an einem VR Simulator 85 4.9 Vorschlag für das Anfängertraining an einem VRT Simulator 91 4.10 Limitierungen der Arbeit 92 4.11 Ausblick 93 5. Zusammenfassung 94 5.1 Summary 96 6. Literatur 98 6.1 Abbildungsverzeichnis 106 6.2 Tabellenverzeichnis 108 7. Anhang 109 7.1 Probandenrandomisierung 109 7.2 Probandeninformationsblatt 110 7.3 Einwilligungserklärung 112 7.4 Beispiel Teilnahmebescheinigung 114 7.5 Zusammenfassung der aufgetretenen Softwarefehler am Lap Mentor II 115 8. Danksagung 116 9. Eigenständigkeitserklärung 117 Anlage 1 118 Anlage 2 120

Historically, the education of surgical navigation in minimally invasive neurosurgery has been constrained by several factors. Medical students have been required to physically be in the operating room to observe a teacher perform the different procedures. This restricts their opportunities to gain valuable hands-on experience in their field. An extended reality simulation system that employs auditory feedback in the form of sonification could be used to provide an inexpensive alternative to this traditional approach. Such a system would allow medical students to get practical experience with valuable insights during their initial years of training without requiring access to the operating room. In order to perform a first evaluation of the impact of sonification on neurosurgical learning using extended reality simulations, a prototype of a surgical simulation tool with six possible sonifications was implemented for the task of aligning a catheter against a target angle. The sonification types studied were spatial, psychoacoustic and direct parameter-mapping, each of which encoded the component angles either in parallel or sequentially. The sonifications were evaluated against each other and the baseline condition in a comparative mixed-design user study measuring the participants efficacy as accuracy, precision, time-to-completion and perceived workload for an assisted neurosurgical simulation task. Participants were found to be significantly slower when using the psychoacoustic sonification as compared to using no aid. Both the spatial and direct sonification showed non-significant tendencies to be slower than the baseline condition. Whilst no significant difference was found between the sonifications, the participants tended to have higher efficacy when using the spatial and direct sonifications, than with the psychoacoustic sonification. Hence these sonifications show the most promise as possible candidates for an auditory feedback system in an extended reality simulator for surgical navigation. However, further evaluation is needed to conclude the full effect of the direct and spatial sonifications on the students’ efficacy. / Utbildningen av kirurgisk navigation för minimalinvasiva neurokirurgiska operationer har historiskt begränsats av flera anledningar. För att kunna lära sig, så har läkarstudenter behövt fysiskt närvara i operationssalen för att observera en lärare genomföra olika operationer. Det har begränsat studenternas möjlighet att få viktig praktisk erfarenhet inom sitt fält. Som ett alternativ till traditionella metoder skulle ett simulationssystem baserat på extended reality (utökat verklighet) och som använder auditiv återkoppling i form av sonifikation kunna användas. Ett sådant system skulle kunna ge läkarstudenter möjligheten att träna praktiskt utanför operationssalen samtidigt som de kan få direkt återkoppling under operationens gång. För att genomföra en första utvärdering av sonifikations påverkan på inlärningen av neurokirurgi när simulationer baserad på extended reality används, så utvecklades en prototyp av en kirurgisk simulator med sex möjliga sonifikationer för uppgiften att positionera en kateter så att den är vinklad i en given riktning. Sonifikationerna byggde på parametrisk mappning baserad på spatiala, psykoakustiska eller direkta metoder. För vardera av de tre metoderna kunde komponent vinklarna antingen kommuniceras parallellt eller sekventiellt. Prototyperna utvärderades mot varandra och basfallet då ingen hjälp användes. Utvärderingen genomfördes som en användarstudie av mixed design (blandad design). Användarnas effektivitet mättes som noggrannhet, precision, använd tid och upplevd arbetsbörda. Deltagarna var signifikant långsammare än basfallet när den psykoakustiska sonifikationen användes. Både den spatiala och direkta sonifikation påvisade en likartad, men icke-signifikanta tendens att va långsammare än basfallet. Medans ingen signifikant skillnad upptäcktes mellan sonifikationerna, så tenderade deltagarna att va mer effektiva när de använde den spatiala och direkta sonifikationerna, i jämförelse med när de använde den psykoakustiska sonifikationen. Därmed verkar dessa två metoder för sonifikation vara de mest lovande kandidater för ett auditivt återkopplingssystem i en extended reality simulator för kirurgisk navigation. Dock behövs vidare utvärdering för att finna en slutsats om spatiala och direkta sonifikationers fulla påverkan på läkarstudenternas effektivitet.

Das Dokument ist ein Corrigendum zu dem veröffentlichten Paper ”Data-Driven Digital Twins in Surgery utilizing Augmented Reality and Machine Learning”. Es enthält Korrekturen zu den fehlerhaften Abschnitten des Originalpapers. / This document is a corrigendum for the published paper 'Data-Driven Digital Twins in Surgery utilizing Augmented Reality and Machine Learning'. It contains corrections for faulty sections of the original paper.

Irreversible electroporation is a minimally invasive technique for the non-thermal destruction of cells in a targeted volume of tissue, using brief electric pulses, (~100 µs long) delivered through electrodes placed into or around the targeted region. These electric pulses destabilize the integrity of the cell membrane, resulting in the creation of nanoscale defects that increase a cell’s permeability to exchange with its environment. When the energy of the pulses is high enough, the cell cannot recover from these effects and dies in a non-thermal manner that does not damage neighboring structures, including the extracellular matrix. IRE has been shown to spare the major vasculature, myelin sheaths, and other supporting tissues, permitting its use in proximity to these vital structures. This technique has been proposed to be harnessed as an advantageous non-thermal focal ablation technique for diseased tissues, including tumors. IRE electric pulses may be delivered through small (ø ≈ 1 mm) needle electrodes, making treatments minimally invasive and easy to apply. There is sub-millimeter demarcation between treated and unaffected cells, which may be correlated with the electric field to which the tissue is exposed, enabling numerical predictions to facilitate treatment planning. Immediate changes in the cellular and tissue structure allow real-time monitoring of affected volumes with imaging techniques such as computed tomography, magnetic resonance imaging, electrical impedance tomography, or ultrasound. The ability to kill tumor cells has been shown to be independent of a functioning immune system, though an immune response seems to be promoted by the ablation. Treatments are unaltered by blood flow and the electric pulses may be administered quickly (~ 5 min). Recently, safety and case studies using IRE for tumor therapy in animal and human patients have shown promising results. Apart from these new studies, previous work with IRE has involved studies in healthy tissues and small cutaneous experimental tumors. As a result, there remain significant differences that must be considered when translating this ablation technique towards a successful and reliable therapeutic option for patients. The dissertation work presented here is designed to develop irreversible electroporation into a robust, clinically viable treatment modality for targeted regions of diseased tissue, with an emphasis on tumors. This includes examining and creating proving the efficacy for IRE therapy when presented with the many complexities that present themselves in real-world clinical patient therapies, including heterogeneous environments, large and irregular tumor geometries, and dynamic tissue properties resulting from treatment. The impact of these factors were theoretically tested using preliminary in vitro work and numerical modeling to determine the feasibility of IRE therapy in heterogeneous systems. The feasibility of use was validated in vivo with the successful treatment of human mammary carcinomas orthotopically implanted in the mammary fat pad of mice using a simple, single needle electrode design easily translatable to clinical environments. Following preliminary theoretical and experimental work, this dissertation considers the most effective and accurate treatment planning strategies for developing optimal therapeutic outcomes. It also experimentally characterizes the dynamic changes in tissue properties that result from the effects of IRE therapy using ex vivo porcine renal cortical tissue and incorporates these into a revised treatment planning model. The ability to use the developments from this earlier work is empirically tested in the treatment of a large sarcoma in a canine patient that was surgically unresectable due to its proximity to critical arteries and the sciatic nerve. The tumor was a large and irregular shape, located in a heterogeneous environment. Treatment planning was performed and the therapy carried out, ultimately resulting in the patient being in complete remission for 14 months at the time of composing this work. The work presented in this dissertation finishes by examining potential supplements to enhance IRE therapy, including the presence of an inherent tumor-specific patient immune response and the addition of adjuvant therapeutic modalities. / Ph. D.

Réalisé sous la co-direction des Drs Denis Bouchard et Michel Pellerin / La sternotomie médiane est l’approche classique pour la chirurgie de la valve mitrale. Elle permet une exposition optimale, mais est associée à un traumatisme chirurgical important, car elle requiert la séparation de l’os sternal. Le présent mémoire porte sur une solution alternative à la sternotomie dans le contexte de la chirurgie mitrale : la chirurgie minimalement invasive (CMI) par minithoracotomie antérolatérale. Trois études ont été réalisées dans le cadre de ce travail. Dans un premier temps, une étude de cohorte regroupant 200 patients consécutifs a permis d’évaluer le taux de succès des réparations mitrales réalisées par minithoracotomie et d’évaluer la durabilité de ces réparations à moyen terme. Par la suite, une étude comparative a été réalisée afin d’évaluer deux méthodes de clampage aortique pour la CMI, soit l’occlusion endovasculaire avec ballon et l’occlusion transthoracique. Enfin, une étude avec analyse par score de propension (propensity score) a permis de comparer la CMI à la sternotomie en ce qui a trait à une complication fréquente en chirurgie cardiaque, l’insuffisance rénale aiguë. La première étude a permis de conclure que la CMI peut être réalisée avec un taux de réparation quasi parfait, et ce malgré la courbe d’apprentissage associée à la technique minimalement invasive. Ces réparations semblent être durables, tel que démontré par une survie sans réopération de 98.3 ± 1.2% à 5 ans. La seconde étude a permis de démontrer que l’occlusion transthoracique est plus fiable que l’occlusion endoaortique et qu’elle est associée à des temps opératoires diminués et à une plus faible incidence de complications procédurales. Enfin, la troisième étude a démontré une association significative entre la CMI et une diminution du risque d’insuffisance rénale aiguë. En conclusion, la minithoracotomie antérolatérale est une excellente alternative à la sternotomie médiane. Tout en diminuant le traumatisme chirurgical, cette approche ne compromet pas la qualité de l’acte chirurgical et présente des bénéfices cliniques. / Median sternotomy is the classic approach for mitral valve surgery. This technique allows optimal exposure but is considered invasive as it requires section of the sternal bone. This thesis discusses an alternative sternotomy : minimally invasive mitral valve surgery (MIMVS) through a right anterolateral minithoracotomy. Three studies were conducted as part of this work. First, a cohort study involving 200 consecutive patients was used to evaluate the success rate of mitral valve repairs performed by minithoracotomy and assess the midterm durability of these repairs. Second, a comparative study was conducted to evaluate two methods of aortic clamping for MIMVS, namely the endovascular balloon occlusion technique and the transthoracic occlusion approach. Finally, a propensity score analysis study was performed to compare MIMVS and sternotomy with respect to a common complication following cardiac surgery : acute renal failure. The first study demonstrated that MIMVS can be performed with a near perfect repair rate, despite the learning curve associated with the minimally invasive technique. These repairs appear to be durable, as evidenced by a freedom from reoperation rate of 98.3 ± 1.2% at 5 years. The second study demonstrated that transthoracic clamping is more reliable than endoaortic occlusion and is associated with shorter operative times and a lower incidence of procedural complications. Finally, the third study found a significant association between MIMVS and a decreased risk of postoperative acute renal failure. In conclusion, the anterolateral minithoracotomy appraoch is an excellent alternative to median sternotomy. While decreasing surgical trauma, this approach does not compromise the quality of surgery and is associated with important clinical benefits.

A artroscopia e a artrocentese são procedimentos considerados minimamente invasivos utilizados para o tratamento das disfunções temporomandibulares (DTM) e são métodos considerados intermediários entre a terapia conservadora e a cirurgia aberta da articulação temporomandibular (ATM). Apresentam como vantagem, em relação a cirurgia aberta, a pequena morbidade e o breve tempo de recuperação necessária aos pacientes. Desde o início do desenvolvimento da artroscopia esteve presente a preocupação com a possibilidade de danos a estruturas internas da ATM, com essa finalidade vários estudos em animais foram desenvolvidos evidenciando que realmente podem ocorrer lesões iatrogênicas as estruturas internas desencadeando processo degenerativo na articulação. A avaliação do mesmo potencial de lesão para artrocentese não existe, assim o objetivo deste trabalho foi avaliar o trauma operatório da artrocentese comparativamente a artroscopia aos tecidos da ATM em suínos. Realizou-se experimento em vinte ATM de dez cabeças de suínos sendo seis artroscopias; seis artrocenteses e oito ATM utilizadas como controle. Após a realização dos procedimentos as ATM foram cuidadosamente dissecadas, examinadas e fotografadas com registro de alterações traumáticas ao disco articular e as fibrocartilagens da fossa articular e da cabeça da mandíbula. As imagens das estruturas foram analisadas por outro examinador que não tinha conhecimento prévio de qual procedimento havia sido realizado em cada ATM classificando as lesões de acordo com o número e localidade em: ausente (sem alteração visível); leve (descolamento de fibrocartilagem da fossa ou cabeça da mandíbula isoladas e únicas), moderado (perfurações do disco e mais de um descolamento de fibrocartilagem da fossa ou cabeça da mandíbula) e severo (lacerações do disco e lesões múltiplas em mais de uma estrutura). Os dados também foram classificados em ausente e presente para uma comparação direta. Foi realizada análise estatística dos dados. No grupo controle ocorreram danos em duas das oito ATM durante a dissecção, que apresentaram características distintas das lesões constatadas após os procedimentos, nas outras seis nenhuma alteração traumática pode ser evidenciada. No grupo submetido a artrocentese os danos foram ausentes, leves e moderados em 16.7% respectivamente e severos em 50% da amostra. No grupo submetido a artroscopia ocorreram danos moderados em 66.7%, severos em 16.7%, ausentes em 16.7% e não ocorreram danos leves. Em ambos os grupos foram evidenciadas a presença de lesões em 83.3% das amostras. Apesar de não haver diferença estatisticamente significativa entre os danos verificados, em uma análise direta, a severidade das lesões constatadas após artrocentese foi maior. Conclui-se que a artrocentese e a artroscopia não são isentas de morbidade aos tecidos articulares e independentemente de serem procedimentos considerados minimamente invasivos não se pode desprezar o potencial de danos as superfícies articulares. / Arthroscopy and arthrocentesis are considered minimally invasive procedures for the treatment of temporomandibular disorders (TMD) and are situated between conservative therapies and open surgery of the temporomandibular joint (TMJ). When compared to open surgery they present the advantages of having a brief post operatory recovery time for the patient and little morbidity. Since the beginning of the development of arthroscopy the possibility of damage to the inner structures of the TMJ was a concern, as a result a series of studies in animals were made and it became clear that iatrogenic damage can really happen and trigger degenerative alterations in the joint. Considering that there are no studies that investigate the potential of causing structural damage to the TMJ during arthrocentesis the objective of this study was to evaluate the operative trauma of arthroscopy and arthrocentesis to the tissues of the TMJ using swine heads. Twenty TMJ of ten swine heads were used for six arthroscopies; six arthrocentesis and eight that were used as a control group. After the procedures the TMJ were carefully dissected, examined and photographed. Traumatic alterations to the articular disk and to the fossa and head of the mandible fibrocartilage were recorded. The images of the structures were analyzed by other examiner that did not had previous knowledge of witch procedure each TMJ was subjected to. The lesions that were identified were classified according to the location and number as: absent (no visible alteration); light (one isolated scuffing of the fibrocartilage of the fossa or the head of the mandible); moderate (disk perforation or multiple scuffing of the fibrocartilage of the fossa or head of the mandible) and severe (disk laceration or multiple lesions in more than one structure). The obtained data was also classified as absent or present for a direct comparison. Statistical analyses of the obtained data were made. In the control group damage to two of the eight TMJ was perceived during dissection, the characteristics of those lesions were clearly different from those observed after the procedures, in the other six none traumatic damage could be noticed. In the arthrocentesis group the damages were absent, light and moderate in 16.7% respectively and were severe in 50% of the sample. In the arthroscopy group damage was moderate in 66.7%, severe in 16.7%, absent in 16.7 and no light damage occurred. In both groups damage was present in 83.3% of the sample. Even though the difference between the groups was not statistically significant, making a direct analysis of the data, the severity of the lesions found in the arthrocentesis group was higher. It was concluded that arthrocentesis and arthroscopy are not absent of morbidity to the TMJ tissues and regarded of being minimally invasive procedures the potential of damage to the structures of the TMJ should not be minimized.

Ο στόχος αυτής της εργασίας είναι να αποκτήσουμε μία βασική γνώση όλων των διαφορετικών σχεδιαστικών παραμέτρων που πρέπει να εξεταστούν για να είναι εφικτή η κατασκευή και ο έλεγχος ενός πολυαρθρωτού εργαλείου. Επιπλέον, όλες οι αναλυτικές μέθοδοι ελέγχου που βασίζονται στις ιδιαιτερότητες των SMA παρουσιάζονται λεπτομερώς, ώστε να παραχθεί μία ικανοποιητική λύση βασιζόμενη στις μεταβολές κατάστασης των κραμάτων και του συγκεκριμένου βραχίονα. Με άλλα λόγια, μία πλήρης γνώση του πώς σχεδιάζουμε, κατασκευάζουμε, προσομοιώνουμε, ελέγχουμε και απεικονίζουμε ένα λειτουργικό μικροσκοπικό πολυαρθρωτό βραχίονα, με τένοντες βασισμένους σε SMA για ελάχιστα επεμβατική χειρουργική είναι ο στόχος της παρούσας εργασίας. / The purpose of this work is to acquire a fundamental knowledge of all the different design parameters, which must be evaluated in order to be able to fabricate and control a multi-DOF manipulator. Moreover, all the analytical control techniques based on the particularities of the shape memory alloys will be shown in details, in order to provide an efficient solution based on the variations of the alloys and the specific manipulator. In other words, the knowhow of building, evaluating, controlling and displaying a functional tiny multi- DOF SMA-based manipulator for minimally invasive surgery is the purpose of this work.

Dans cette thèse, nous apportons la contribution à la conception de robots médicaux, en proposant une démarche de conception simultanée de la structure mécanique du robot. Par opposition à une vision séquentielle naturelle de la conception, la formalisation du processus créatif permet une simultanéité, ouvrant la voie à des structures innovantes dédiées : en robotique médicale, faible masse et faible compacité de la structure mécanique sont souvent recherchées. A partir d’un descriptif de démarches existantes, nous effectuons la conception d’un robot de télé-échographie et d’un robot de chirurgie mini-invasive. Pour les deux applications, de fortes contraintes sont présentes. En télé-échographie, la portabilité est très recherchée, requérant une faible compacité. Pour la chirurgie mini-invasive, les moto-réducteurs du robot in vivo doivent être dimensionnés au plus juste. Ici, nous avons formalisé l’amélioration de la compacité d’une structure parallèle pour la télé-échographie. Les résultats montrent une amélioration de la compacité de l’ordre de 5%. Dans le même esprit, nous avons formalisé la synthèse dimensionnelle de deux robots 2R-R-R de chirurgie mini-invasive in vivo. Nous réalisons l’optimisation simultanée entre le dimensionnement des moto-réducteurs et des longueurs des corps pour tendre vers une simultanéité totale du processus créatif, ce qui nous permet d’améliorer les performances en termes de force et vitesse à l’effecteur. Ces expériences de conception montrent les limites à une simultanéité stricte. Nous indiquons le besoin d’adapter outils et méthodes de conception mécatronique pour une simultanéité en conception robotique tenant compte de l’aspect imparfait du processus créatif. / In this thesis, we propose a contribution to the design of medical robots, by offering a concurrent design or simultaneous approach. As opposed to a natural sequential view of the design process, the formalization of the creative process allows simultaneity, paving the way for innovative structures, dedicated: in the medical robotic field, low mass and low compactness of the mechanical structure are often sought. From a description of existing approaches, we design a tele-ultrasound robot and a minimally invasive surgery robot. For both applications, high physical integration is required. For tele-ultrasound robots, portability is highly sought, requiring low compactness. For minimally invasive surgery, geared motors of the in vivo robot must be sized correctly. Here, we formalized the improvement of compactness of an existing parallel structure for remote ultrasound application. The results show an improvement of compactness of around 5%. In the same way, we formalize the dimensional synthesis of two robots 2R-R-R for in vivo minimally invasive surgery. The results show the under-sizing of some actuators. We perform simultaneous optimization between the design of geared motors and lengths of the body of a robot 2R-RR, tendering towards full simultaneity of the creative process, allowing to improve minimal force and velocity at the end-effector of the robot. These experiments of design show limits to a strict simultaneity. We indicate the need to adapt the tools and methods of mechatronic design for simultaneous robotics design, taking into account the imperfect aspect of the creative process.

A artroscopia e a artrocentese são procedimentos considerados minimamente invasivos utilizados para o tratamento das disfunções temporomandibulares (DTM) e são métodos considerados intermediários entre a terapia conservadora e a cirurgia aberta da articulação temporomandibular (ATM). Apresentam como vantagem, em relação a cirurgia aberta, a pequena morbidade e o breve tempo de recuperação necessária aos pacientes. Desde o início do desenvolvimento da artroscopia esteve presente a preocupação com a possibilidade de danos a estruturas internas da ATM, com essa finalidade vários estudos em animais foram desenvolvidos evidenciando que realmente podem ocorrer lesões iatrogênicas as estruturas internas desencadeando processo degenerativo na articulação. A avaliação do mesmo potencial de lesão para artrocentese não existe, assim o objetivo deste trabalho foi avaliar o trauma operatório da artrocentese comparativamente a artroscopia aos tecidos da ATM em suínos. Realizou-se experimento em vinte ATM de dez cabeças de suínos sendo seis artroscopias; seis artrocenteses e oito ATM utilizadas como controle. Após a realização dos procedimentos as ATM foram cuidadosamente dissecadas, examinadas e fotografadas com registro de alterações traumáticas ao disco articular e as fibrocartilagens da fossa articular e da cabeça da mandíbula. As imagens das estruturas foram analisadas por outro examinador que não tinha conhecimento prévio de qual procedimento havia sido realizado em cada ATM classificando as lesões de acordo com o número e localidade em: ausente (sem alteração visível); leve (descolamento de fibrocartilagem da fossa ou cabeça da mandíbula isoladas e únicas), moderado (perfurações do disco e mais de um descolamento de fibrocartilagem da fossa ou cabeça da mandíbula) e severo (lacerações do disco e lesões múltiplas em mais de uma estrutura). Os dados também foram classificados em ausente e presente para uma comparação direta. Foi realizada análise estatística dos dados. No grupo controle ocorreram danos em duas das oito ATM durante a dissecção, que apresentaram características distintas das lesões constatadas após os procedimentos, nas outras seis nenhuma alteração traumática pode ser evidenciada. No grupo submetido a artrocentese os danos foram ausentes, leves e moderados em 16.7% respectivamente e severos em 50% da amostra. No grupo submetido a artroscopia ocorreram danos moderados em 66.7%, severos em 16.7%, ausentes em 16.7% e não ocorreram danos leves. Em ambos os grupos foram evidenciadas a presença de lesões em 83.3% das amostras. Apesar de não haver diferença estatisticamente significativa entre os danos verificados, em uma análise direta, a severidade das lesões constatadas após artrocentese foi maior. Conclui-se que a artrocentese e a artroscopia não são isentas de morbidade aos tecidos articulares e independentemente de serem procedimentos considerados minimamente invasivos não se pode desprezar o potencial de danos as superfícies articulares. / Arthroscopy and arthrocentesis are considered minimally invasive procedures for the treatment of temporomandibular disorders (TMD) and are situated between conservative therapies and open surgery of the temporomandibular joint (TMJ). When compared to open surgery they present the advantages of having a brief post operatory recovery time for the patient and little morbidity. Since the beginning of the development of arthroscopy the possibility of damage to the inner structures of the TMJ was a concern, as a result a series of studies in animals were made and it became clear that iatrogenic damage can really happen and trigger degenerative alterations in the joint. Considering that there are no studies that investigate the potential of causing structural damage to the TMJ during arthrocentesis the objective of this study was to evaluate the operative trauma of arthroscopy and arthrocentesis to the tissues of the TMJ using swine heads. Twenty TMJ of ten swine heads were used for six arthroscopies; six arthrocentesis and eight that were used as a control group. After the procedures the TMJ were carefully dissected, examined and photographed. Traumatic alterations to the articular disk and to the fossa and head of the mandible fibrocartilage were recorded. The images of the structures were analyzed by other examiner that did not had previous knowledge of witch procedure each TMJ was subjected to. The lesions that were identified were classified according to the location and number as: absent (no visible alteration); light (one isolated scuffing of the fibrocartilage of the fossa or the head of the mandible); moderate (disk perforation or multiple scuffing of the fibrocartilage of the fossa or head of the mandible) and severe (disk laceration or multiple lesions in more than one structure). The obtained data was also classified as absent or present for a direct comparison. Statistical analyses of the obtained data were made. In the control group damage to two of the eight TMJ was perceived during dissection, the characteristics of those lesions were clearly different from those observed after the procedures, in the other six none traumatic damage could be noticed. In the arthrocentesis group the damages were absent, light and moderate in 16.7% respectively and were severe in 50% of the sample. In the arthroscopy group damage was moderate in 66.7%, severe in 16.7%, absent in 16.7 and no light damage occurred. In both groups damage was present in 83.3% of the sample. Even though the difference between the groups was not statistically significant, making a direct analysis of the data, the severity of the lesions found in the arthrocentesis group was higher. It was concluded that arthrocentesis and arthroscopy are not absent of morbidity to the TMJ tissues and regarded of being minimally invasive procedures the potential of damage to the structures of the TMJ should not be minimized.

Les maladies valvulaires constituent une cause importante de morbidité et de mortalité. Dans les pays industrialisés, l’insuffisance mitrale et la sténose aortique sont les pathologies valvulaires les plus fréquentes et leur prévalence augmentent avec l’âge. Étant donné l’augmentation de l’espérance de vie dans ces pays, la prévalence des valvulopathies dégénératives deviendra plus importante et aura un impact non négligeable sur la santé publique. Les avancées en chirurgie cardiaque ainsi que les nouvelles percées en cardiologie interventionnelle ont modifié considérablement la prise en charge des patients avec des valvulopathies en offrant des approches minimalement invasives, surtout pour les patients à haut risque chirurgical. Dans le cadre de ce mémoire, deux études rétrospectives de cohorte ont été réalisées. La première consiste à comparer les résultats postopératoires et sur trois ans de la chirurgie conventionnelle par rapport à la procédure transcathéter MitraClip chez 259 patients avec une insuffisance mitrale ischémique sévère. La deuxième étude compare les résultats postopératoires de trois approches de remplacement de la valve aortique, soit la sternotomie, la ministernotomie et la minithoracotomie. La première étude permet de conclure que la procédure MitraClip a un taux de mortalité postopératoire et sur 3 ans inférieur à celui de la chirurgie mais qu’elle est associée à un plus haut taux de récurrence de l’insuffisance mitrale après 3 ans. La deuxième étude démontre que les deux approches minimalement invasives, la ministernotomie et la mini-thoracotomie, ont un taux équivalent de mortalité intra-hospitalier à la sternotomie. La mini-thoracotomie est associée à moins de saignement périopératoire et moins de douleur au repos que la sternotomie. En conclusion, les approches minimalement invasives offrent une excellente alternative à la chirurgie conventionnelle dans le traitement de la maladie valvulaire. Les bénéfices cliniques sont d’autant plus évidents lorsque les patients sont adéquatement sélectionnés; d’où l’importance d’une ‘Heart Team’ qui collabore pour une meilleure prise en charge des patients. / Valvular heart disease is an important cause of morbidity and mortality. In western countries, mitral regurgitation and aortic stenosis are the most frequent valvular pathologies and their prevalence increases with age. With the increase in life expectancy in these countries, the prevalence of degenerative valve disease will increase with a significant burden on healthcare systems. Advances in cardiac surgery as well as new breakthroughs in interventional cardiology have considerably modified the management of patients with valvular disease, by offering minimally invasive approaches, especially for patients at high surgical risk. In this thesis, two retrospective cohort studies were carried out. The first compares the postoperative and 3 years outcomes of mitral valve surgery vs MitraClip, a transcatheter procedure, in 259 patients with severe ischemic mitral regurgitation. The second study compares the postoperative results of two minimally invasive techniques (ministernotomy and minithoracotomy) for aortic valve replacement to conventional sternotomy. In the first study, MitraClip procedure had lower postoperative and 3-year mortality rate than surgery, but it was associated with higher recurrence rate of mitral regurgitation after 3 years. The second study showed that the two minimally invasive approaches had similar intrahospital mortality rate to sternotomy. Minithoracotomy was associated with less perioperative bleeding and less pain at rest than sternotomy. In conclusion, minimally invasive approaches offer an excellent alternative to conventional surgery in the treatment of valvular disease. The clinical benefits are more highlighted when patients are properly selected; hence the importance of a "Heart Team" that collaborates for better patient care.