Tiefe sternale Wundheilungsstörungen sind seltene, aber verheerende Komplikationen nach medianer Sternotomie. Die verminderte Durchblutung von Knochen- und Weichgewebe nach Verwendung der Arteria thoracica interna (ITA) in der kardiochirurgischen Bypass-Chirurgie, begünstigt die Entwicklung von Wundheilungsstörungen. Das Ziel dieser Studie war die makroskopische und radiologische Darstellung des sternalen Gefäßsystems im Hinblick auf mögliche Kollateralkreisläufe. Das methodische Vorgehen gliederte sich in die makroskopischen Präparation, die Segmentierung mittels Mimics® und deren semi-quantitativer Vergleich. Bei der makroskopischen Präparation wurden vier Thorax-Schilde (vordere Brustwand), zwei Alkohol- und zwei Thiel-fixierte Schilde, entnommen und die ITA und deren Abgänge präpariert. Da nach Thiel-Fixierung Gewebe realitätsnahe Eigenschaften behalten, blieben die weichen Gefäße durchgängig und eigneten sich besonders zur Injektion des Microfil®-Gemisches oder der Arterienmasse nach Thiel (1992). Ein weiterer Vorteil der Massen war die Röntgenopazität, wodurch radiologische Untersuchungen am Präparat erfolgten. Da die segmentierungsbasierte Rekonstruktion zunehmend Einzug in die Diagnostik hält, wurden zur Diskussion, ob Kollateralkreisläufe des Sternums dargestellt werden können, zwei Thorax-CTs erstellt und mittels Mimics® segmentiert. Die im Rahmen dieser Studie angewandten Methoden konnten das makroanatomische Gefäßsystem des Sternums darstellen, wobei die Injektion der Arterienmasse am Thiel fixierten Humanpräparat mit anschließender Segmentierung besonders geeignet war.:Inhaltsverzeichnis Abkürzungen viii 1 Einleitung 1 1.1 Problemstellung 1 1.2 Anatomie des Thorax 2 1.2.1 Anatomie des knöchernen Thorax 3 1.2.2 Anatomie des Sternums 3 1.2.2.1 Blutversorgung des Sternums 5 1.3 Die A. thoracica interna (ITA) 6 1.4 Die mediane Sternotomie 8 1.5 Tiefe sternale Wundheilungsstörungen (DSWI) 9 1.5.1 Definition DSWI 9 1.5.2 Risikofaktoren DSWI 11 1.5.3 Therapie 12 1.6 Methoden zur Darstellung der Gefäßversorgung des Sternums 14 1.6.1 Allgemeines 14 1.6.2 Fixierung und Konservierung 14 1.6.3 Präparations- und Injektionstechnik 15 1.6.4 Segmentierungsbasierte Rekonstruktion mit Mimics® 15 2 Material und Methodik 17 2.1 Untersuchungsmaterial 17 2.2 Fixierungen 19 2.2.1 Alkohol-Fixierung 19 2.2.2 Thiel-Fixierung 21 2.3 Übersicht der Methodik 27 2.4 Makroskopische Präparation 28 2.4.1 Präparation des Thorax-Schildes 28 2.4.2 Präparation der ITA und ihrer Abgänge 31 2.5 Injektionstechniken am Thiel-fixierten Präparat 33 2.5.1 Anwendung des Microfil®-Gemisches 33 2.5.2 Arterienmasse nach Thiel für die makroskopische Präparation 37 2.6 Segmentierungsbasierte Rekonstruktion mittels Mimics® 45 2.6.1 Kontrastmittel-CT 49 2.6.2 Arterienmasse nach Thiel für die Computertomographie 54 2.7 Semi-quantitative Beurteilung der Methoden 56 2.8 Systematische Literaturrecherche 58 2.9 Statistische Auswertung 61 2.10 Fotografische und bildliche Dokumentation der Präparate 61 3 Ergebnisse 62 3.1 Makroskopische Präparation der ITA und ihrer Abgänge 62 3.1.1 Länge der ITA 62 3.1.2 Abgänge der ITA 63 3.2 Semi-quantitative Beurteilung der makroskopischen Präparation 67 3.2.1 Alkohol-fixierte Präparate 67 3.2.2 Thiel-fixierte Präparate 69 3.2.2.1 Thorax-Schild ohne Injektionstechnik 69 3.2.2.2 Thorax-Schild mit Injektionstechnik - Microfil®-Masse 71 3.2.2.3 Thorax-Schild mit Injektionstechnik – Arterienmasse nach Thiel 75 3.3 Semi-quantitative Beurteilung der segmentierungsbasierten Rekonstruktion mit Mimics® 78 3.3.1 Kontrastmittel-CT 79 3.3.2 Arterienmasse nach Thiel 86 4 Diskussion 98 4.1 Länge der ITA 99 4.2 Methodenvergleich zur Darstellung der ITA 99 4.2.1 Alkohol- vs. Thiel-Fixierung (ohne Injektion) 101 4.2.2 Alkohol- vs. Thiel-Fixierung (Microfil®) 102 4.2.3 Arterienmasse nach Thiel vs. Microfil® 103 4.3 Segmentierungsbasierte Rekonstruktion 105 4.3.1 Interpretation der Bilder und Methodenvergleich 106 4.4 Vergleich mit anderen Methoden zur Gefäßdarstellung 109 4.5 Schlussfolgerung 112 5 Zusammenfassung 113 6 Literaturverzeichnis 115 7 Abbildungsverzeichnis 120 8 Tabellenverzeichnis 123 9 Danksagung 124 10 Ehrenwörtliche Erklärung 125 11 Lebenslauf 126 12 Anhang 127

La méthode de conservation des cadavres selon Walter Thiel a été publiée en 1992. Cette technique, contrairement aux techniques classiques, permet de garder au cadavre une certaine souplesse, proche du sujet vivant. Depuis sa description initiale, cette technique s’est peu développée, malgré des possibilités très intéressantes pour les cliniciens soucieux d’apprendre et de perfectionner leurs gestes médico-chirurgicaux par simulation. En effet, la simulation en médecine est en train d’apporter une révolution pédagogique afin que les étudiants n’apprennent plus directement sur le patient les gestes à potentiel iatrogène important, mais sur des simulateurs. La question soulevée par notre travail est celle de ce double paradoxe : la technique de Thiel est très intéressante mais pourtant ne se développe pas beaucoup, et d’autre part, la simulation connait un essor considérable mais ne prend pas beaucoup en compte le potentiel de l’apprentissage sur cadavres. A la lumière de plusieurs travaux explorant divers aspects de la méthode de Thiel, nous démontrerons les possibilités des cadavres conservés par cette méthode en termes d’applications cliniques pour l’enseignement et la recherche par simulation en anesthésie et en chirurgie. / Walter Thiel’s method for the preservation of cadavers was published in 1992. Unlike conventional preservation techniques, this method provides a spectacular lifelike flexibility. Despite of its interesting possibilities in learning and training for clinical practitioners, this technique has had a poor development around the world. Simulation represents a revolution in medical education because it allows students to train before act on real patients, particularly the situations with a high iatrogenic risk. The question raised by our work is that this double paradox: the Thiel’s method is very interesting but still not well developed, and secondly, the simulation has expanded enormously but does not take much account of the potential learning on cadavers. In several studies exploring various aspects of Thiel’s method, we will demonstrate the possibilities of cadavers preserved by this method in terms of clinical applications for teaching and research in the fields of simulation in anesthesia and surgery.

This multifaceted study documents validates, and verifies the changes in oral surgery teaching in Dundee University Dental School, which have changed with time to accommodate the demands of an ever increasingly complex discipline. Availability of instructive teaching material in hard copy and as video and text on the internet combined with close clinical supervision and detailed assessment with feedback allows students to attain competency in exodontia with falling patient numbers. It has been demonstrated that the undergraduate training in the oral surgery clinics still attains competency or BDS standard of ‘safe beginner’ for simple extractions and minor oral surgery, despite fewer procedures being carried out. The criteria used for undergraduate assessment and marking of exodontia have been validated in house and nationally. These are appropriate, objective and reliable. Using Thiel cadavers is a valid and reliable method of teaching undergraduate students the technique of extraction with forceps prior to their clinical exposure. Further employment of the cadavers for continuing practice and the introduction of new skills has been mooted. The use of the ‘Blackboard’ was investigated and found not to be well used; the effort to produce the work was not well directed since it was not taken advantage of by the whole year nor very frequently by those who do use it. Alternative methods of engaging the student to investigate and research the discipline have been suggested. Encouragement of the students to interact more when the exodontia clinic time is available for this opportunity has been introduced and suggestions to increase this activity to enhance the teaching of core topics have been made. From apprehension to enjoyment our student assure us that they find this discipline worthwhile whilst acknowledging that it will not be a practice builder and that they are equipped to deal with simple oral surgery procedures.

This paper presents an intraoperative MRI-guided, patient-mounted robotic system for shoulder arthrography procedures in pediatric patients. The robot is designed to be compact and lightweight and is constructed with nonmagnetic materials for MRI safety. Our goal is to transform the current two-step arthrography procedure (CT/x-ray-guided needle insertion followed by diagnostic MRI) into a streamlined single-step ionizing radiation-free procedure under MRI guidance. The MR-conditional robot was evaluated in a Thiel embalmed cadaver study and healthy volunteer studies. The robot was attached to the shoulder using straps and ten locations in the shoulder joint space were selected as targets. For the first target, contrast agent (saline) was injected to complete the clinical workflow. After each targeting attempt, a confirmation scan was acquired to analyze the needle placement accuracy. During the volunteer studies, a more comfortable and ergonomic shoulder brace was used, and the complete clinical workflow was followed to measure the total procedure time. In the cadaver study, the needle was successfully placed in the shoulder joint space in all the targeting attempts with translational and rotational accuracy of 2.07 ± 1.22mm and 1.46 ± 1.06 degrees, respectively. The total time for the entire procedure was 94 min and the average time for each targeting attempt was 20 min in the cadaver study, while the average time for the entire workflow for the volunteer studies was 36 min. No image quality degradation due to the presence of the robot was detected. This Thiel-embalmed cadaver study along with the clinical workflow studies on human volunteers demonstrated the feasibility of using an MR-conditional, patient-mounted robotic system for MRI-guided shoulder arthrography procedure. Future work will be focused on moving the technology to clinical practice.

En chirurgie vasculaire, l’accès à l’artère fémorale, qu’il soit par une incision chirurgicale ou par une approche percutanée, est très fréquemment utilisé pour une multitude d’interventions vasculaires ou endovasculaires; pour des pontages divers, le traitement d’occlusions artérielles, la réparation d’anévrismes et la pose d’endoprothèses. L’objectif général de ce projet de recherche est de faciliter et réduire les risques des approches de l’artère fémorale par une meilleure compréhension anatomique du triangle fémoral. La méthodologie a été réalisée grâce à l’utilisation de cadavres spécialement embaumés par la méthode développée par Walter Thiel. Les résultats présentés dans ce mémoire ont permis de proposer des solutions en réponse à des problèmes cliniques en chirurgie vasculaire. Dans un premier temps, l’étude de la vascularisation cutanée du triangle fémoral a mené à proposer de nouvelles incisions chirurgicales afin de limiter la dévascularisation cutanée des plaies et ainsi réduire les problèmes de cicatrisation observés. Ensuite, nous avons validé l’identification radiographique et échographique de l’artère fémorale à son croisement avec le ligament inguinal afin de faciliter l’identification d’un site de ponction artérielle adéquat. Enfin, nous avons développé une méthode échographique simple qui facilite l’approche percutanée de l’artère fémorale, même chez les patients obèses. Les retombées de ce projet de recherche sont multiples pour les cliniciens, l’étude fournit une meilleure compréhension anatomique tridimensionnelle du triangle fémoral et les techniques proposées dans ce mémoire pourront apporter une amélioration de la pratique chirurgicale et faciliter le travail des médecins. Toutefois, ces propositions devront maintenant être validées en clinique. / In vascular surgery, access to the femoral artery is frequently used either through a surgical incision of the groin or by a percutaneous approach in a wide variety of vascular and endovascular procedures; for multiple bypasses, treatment of arterial occlusions, aneurysms repair and placement of various stents. The general purpose of this study is to facilitate and reduces the risks of both the surgical and the percutaneous approaches of the femoral artery through a better anatomical understanding of the femoral triangle. The methodology was conducted on specifically embalmed cadavers according to the method developed by Walter Thiel. The results presented in this memory allowed us to propose solutions to clinical problems in vascular surgery. First, the study of the cutaneous vascularisation of the femoral triangle led to suggest new surgical approaches in order to reduce lesions of the cutaneous arteries and the potential devascularization of the borders of the wound yielding a better postoperative outcome. Then, we validated the radiographic and ultrasonographic position and identification of the inguinal ligament and the proximal femoral artery to facilitate the identification of a safe arterial puncture site. Moreover, we developed a simple method for ultrasound-guided arterial puncture, suitable for obese patients, to facilitate the percutaneous approach of the femoral artery. The benefits of this research project are multiple for clinicians, the study provides a better tridimensional anatomic understanding of the femoral triangle and the techniques proposed will lead to an improved surgical practice and facilitate the work of doctors. However, our work and propositions still need to be validated clinically.

This bachelor thesis evolves around the topic of art collectors as a phenomenon throughout different centuries. Ernest Thiel was a Swedish art collector at the turn of- and early 20th- century. Tom Böttiger is a contemporary art collector who acquired his first artwork during the 80’s. Both collectors are more like than alike, which points to and enforces certain common stereotypes as to whom could be a collector and what kinds of collectors exist. This thesis compares those two collectors from different times, from an art collectors perspective. The thesis concluded that collectors often bring upon themselves to act as patrons for the artists, both by promoting and purchasing their works, but also by aiding them financially.

This essay aims to examine whether the Swedish patron Ernest Thiel had any aesthetic influence on the contemporary art scene in the late nineteenth and early twentieth century. Based on a selected group of his commissioned artworks, the study analyzes to what extent Thiel was involved in the creative process. The applied method consists of Panofsky’s iconographical- iconological method, a study of primary sources and literature of art history, and a contextual analysis based on Anne D’Alleva’s theory. The chosen method shows that Ernest Thiel was not engaged in the creative process of his commissioned artworks. Correspondence between Thiel and the commissioned artist reveal that Thiel acted more as afinancial patron, leaving the aesthetics to the artist. Rather than providing his own artistic directives, the intention with his commissioned artworks suggests that his aim was to promote and encourage the artists’ own sense of style. Furthermore, this act of patronage illustrates his genuine appreciation for the artist he supported. This study also exposes the lack of knowledge of the portrait “Porträtt av Hjalmar Söderberg” and the artistry of Gerda Wallander, from whom Thiel commissioned his artwork. The study therefore suggests further research of Gerda Wallander’s artistry as well as of Ernest Thiel’s commissioned artworks, since this is uncharted territory in art history.

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