This approach, which encompasses both a linguistic and conceptual dimension that are interrelated, has been more recently described by Roche (2012, 2015), Costa (2013) and Santos & Costa (2015) . According to Roche (2015: 136), Terminology is “both a science of objects and a science of terms”. For Costa (2013) , it is precisely this double dimension, and the study of the relationship between one and the other that makes Terminology assume its role as an autonomous scientific subject.

This double dimension approach implies, therefore, that both the experts’ conceptualization of a given subject field and the discourses produced by them must be taken into account. The cornerstone of this approach lies in the complementarity of these two fundamentally different dimensions. Understanding the relationship between the two dimensions is crucial in terminology work, as it will contribute to define a methodology that will not compromise the main goal of a terminological project as it is understood in this paper, which is to represent, organize and share the knowledge from a domain, based on the way it is conceptualized by a community of experts.

Consequently, it is believed that experts are indispensable to terminology work, working collaboratively with the terminologist in the different steps of the project, in order to identify the key concepts of the subject field, as well as the way they relate to each other and how they are represented (cf. Costa et al., 2012)

Nonetheless, and bearing in mind what was described in the introductory section, it is of paramount importance that the terminological products may, at some point, be operationalized, i.e. have a computational representation, and thus a more effective impact on the everyday life of the different target groups within the various subject fields.

The rising interest in the aforementioned conceptual and linguistic dimension, as well as in the subsequent synergies involving Terminology and ontologies has led to the emergence of new theoretical perspectives7, one of which being Ontoterminology. 2.2

Proposed by Roche et al. (2009), Ontoterminology aims to reconcile Terminology’s linguistic and conceptual dimensions while maintaining their fundamental differences. Defined as a “terminology whose conceptual system is a formal ontology” (Roche et al., 2009: 325) , this approach considers the conceptualization of a given subject field as the starting point of any terminological project, thus corroborating ISO 704’s view that “producing a terminology requires an understanding of the conceptualization that underpins human knowledge in a subject area” (2009: 3).

As mentioned in 2.1, the expert plays an essential role throughout the process. However, Roche (2007) believes there may be risks inherent to the extraction of ontologies directly from texts, since very often, and due to inconsistencies, ellipses, metaphors and other phenomena, the lexical networks extracted from texts may not match the conceptual systems created with the help of the experts – hence, the discourse about knowledge should not be confused with knowledge itself: “Saying is not Modelling” (2007).

This is not to say, though, that natural language should be excluded from terminology work. In fact, “to conceptualize one must verbalize” (Roche, 2015: 149) . Resorting to specialized texts is indeed relevant8, although it must be taken into account that texts do not contain concepts per se, but the linguistic usages of the terms that designate them. All in all, specialized texts constitute an invaluable resource to the terminologist, especially in their first contact with a given 7 “Termontography” has been developed by the CVC in Brussels within the scope of the FF Poirot European Project and seeks to integrate ontologies in terminology work by combining Ontology Engineering, Terminography and Corpus Linguistics (Kerremans et al. (2004); Kerremans & Temmerman (2004); Temmerman & Kerremans (2003)). Despite the fact they do not share the same goals and are based on a different theoretical and methodological framework, comparing these approaches is not the purpose of this paper. 8 And, in some cases, even indispensable, especially in the legal field, where texts are the pillar of expert knowledge and communication (see Costa et al. 2011, 2013) . domain, and the experts can – and should – play a critical role in advising the terminologist as to the texts that are deemed representative and/or mandatory in a given area.

Access to both linguistic and extra-linguistic knowledge is essential to any terminological project, provided the text selection is supported by rigorous criteria and the methodology/-ies used are consistent with the type of resource being created, its purpose(s), target group(s) and respective needs9.

Instead of making them incompatible, the Ontoterminology approach aims to integrate the linguistic and the conceptual dimensions whilst preserving their core identities. This is visible in Roche’s (2012) extension of the classical semantic triangle by Ogden and Richards (1923), called the “double semiotic triangle” (Figure 1). 9 Santos & Costa (2015) advocate a mixed methodology in terminological work (onomasiological and semasiological), although they argue that the order “is not arbitrary” (p. 176). For knowledge representation purposes, a concept-based approach may constitute a more adequate starting point. 10 The formal language supporting concept definitions should allow these to be objective (not depending on an individual interpretation), consistent and constructive (allowing the conceptualization to be computationally manipulated) (Roche, 2015) . 11 A more thorough analysis on the role of the non-verbal in terminology and knowledge representation may be found, for instance, in Galinski & Picht (1997); Picht (1999, 2011); icine is one of such domains: Figure 2 depicts the female reproductive system of a woman suffering from endometriosis, and it includes the extent and location of the disease in terms of lesions and adhesions.

Far from seeing a mere illustration, a subject field expert would immediately recognize a case of Stage-IV (severe) endometriosis. Rather than being regarded as signs from a Saussurean perspective, the terms that can be identified here (“peritoneum”, “culdesac”, “deep endo”, “complete obliteration”, “dense adhesions”, etc.) should be perceived as signs in the sense of William of Ockham, for whom a sign is “tout ce qui, étant appréhendé, fait connaître quelque chose d’autre” (cf. 1988: 7)12.

The potential of the ontoterminological approach, supported by the acknowledgement of Terminology’s double dimension, provides an opportunity to make a contribution to the subject field of Medicine, in particular to <Endometriosis>, allowing the creation of EndoTerm, a multilingual resource that comprises both verbal and non-verbal representation and that can be computationally represented and manipulated13. Madsen (forthcoming); Roche (forthcoming); PrietoVelasco (forthcoming). 12 It is clear that, on the one hand, we do find terms in discourse that give rise to the construction of meaning – a signifié in the Saussurean sense, i.e. they acquire value in discourse. On the other hand, and as signs, terms also have the capacity to exist outside of discourse (Ockham’s perspective), pointing towards the concept and thus providing access into the specialized domain. 13 A first glimpse of which can be see in Section 4. 3

Endometriosis is defined as “the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction” (Kennedy et al., 2005). The exact prevalence of the disease is unknown, but it is believed to affect an estimated 176 million women of reproductive age worldwide (Adamson et al., 2010) . While its etiology is uncertain, it is likely to be multifactorial, including genetic, immunological, endocrinological and environmental influences.

Women with endometriosis typically have a range of pain-related symptoms, such as dysmenorrhea, dyspareunia, dyschezia, dysuria, non-cyclical pelvic pain, as well as chronic fatigue (Dunselman et al., 2014) . A recent study conducted in 10 countries throughout the world has reported an overall diagnostic delay of 6.7 years (Nnoaham et al., 2011) . Moreover, the World Endometriosis Research Foundation (WERF) EndoCost study (Simoens et al. (2012) has shown that the costs arising from women with endometriosis treated in referral centers are substantial (an average annual total cost per woman of €9579), an economic burden that is at least comparable to the costs of other chronic diseases, such as diabetes, Crohn’s disease, or rheumatoid arthritis.

Surgical procedures play a key role in the diagnosis and treatment of the disease and are often depicted in the form of videos, which is why they were chosen as the focus of the case study to be presented in Section 417. 3.2

The Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT) is a comprehensive, multilingual healthcare terminology, resulting from the merge of the Systematized Nomenclature of Pathology (SNOP), published by the College of American Pathologists, and the Clinical Terms Version 3 (former Read Codes), designed by the UK’s National Health Service18. When implemented in an application, and due to the Description Logic foundation of this tool, SNOMED-CT enables the representation of clin17 Laparoscopy plus histology of resected endometriosis is, in fact, considered the “gold standard” in the diagnosis of this condition (Dunselman et al., 2014) . 18 It is currently owned and distributed by the International Health Terminology Standards Development Organisation (IHTSDO). ical content in electronic health formats (e.g. EHR) in a consistent, reliable and computerreadable way19.

The building blocks of this resource are the: i) concepts, representing clinical meanings and organized into hierarchies, ranging from general to specific (with 19 top-level concepts); ii) descriptions, which link appropriate humanreadable terms to concepts; and iii) relationships, connecting concepts to other related concepts20. Each one of these three components has their own unique numeric identifier. Figure 3 illustrates the results obtained for <Endometriosis> in SNOMED-CT.

In the blue box on the top left corner, it can be seen that <Endometriosis (disorder)> is the concept name, and it coincides with the so-called Fully Specified Name (FSN), whereas “Endometriosis (clinical)” is the preferred synonym and “Endometriosis” the acceptable synonym. The Parents and Children elements refer to the “supertypes” and the “subtypes” of the concept in question, linked via |Is a| relationships. 19For more information, see: http://www.ihtsdo.org/snomedct; https://elearning.ihtsdotools.org 20 The relationships in SNOMED-CT express defining characteristics of a concept and they can be divided into: a) subtype hierarchy relationships (Is a); or b) attribute relationships, which have a particular value provided by another concept, i.e. procedure concepts are linked, for instance, to certain sites.

It should be noted that the subtype concepts are mainly related to the different organs or body parts where the disease can be located (e.g. bladder, intestine, etc.). There are further subdivisions in some of the Children that have not been included due to space constraints.

The final diagram represents the two types of concept relationships associated to <Endometriosis (disorder)>, distinguished by colours and types of arrows. The purple concept is an upperlevel SNOMED-CT concept, linked to the initial concept by a |Is a| relationship. The yellow bubbles display an attribute relationship [has Associated morphology] and [has definitional manifestation] between the initial concept and <Endometriosis (morphological abnormality)> and <Pain (finding)>, respectively.

As previously mentioned, the EndoTerm project aims at the creation of a multilingual21 terminological resource based around the concept of <Endometriosis>. This will be destined to future experts and to experts of other, related domains, mainly for training purposes. One of the objectives is to integrate the resource in an e-learning platform.

Since there are very few specialized texts about this disease in European Portuguese (EP), as most experts publish in English, it is believed a contribution could also be made to enrich the domain terminology in EP and, simultaneously, to improve linguistic quality criteria, which, in 4 4.1 21 In English, European Portuguese and French. German might be included at a later stage of the project. the future, might be applied to other projects involving information retrieval.

Although the inclusion of both verbal and non-verbal elements had already been foreseen in the project, due to the importance of the latter in this particular subject field, the group of experts that have been collaborating in this endeavour suggested the analysis of a type of resource that is becoming more and more important within the medical community: the video article22.

By combining verbal (narration from the expert(s), slides with text, etc.) and non-verbal elements (2D or 3D images, animations, surgery footage), video articles constitute a noteworthy resource to take into account in the light of Terminology’s double dimension. As a new type of scholarly communication that seems to be here to stay, its inclusion in a specialized corpus in a medical terminology project may become inevitable, which will, in turn, pose interesting theoretical and methodological challenges. 4.2

<LESS surgery>: the case study The case study presented in this paper is based on a video article entitled “Single port laparoscopy”23, which portrays a gynecological procedure – in this case, a hysterectomy, commonly seen as a last resort in cases of severe endometriosis – using a relatively recent type of surgery called single port laparoscopy.

The further study of the concept <Single port laparoscopy> pointed towards a lack of terminological consensus among the expert community. In fact, more than 20 acronyms used to designate this concept have been identified in the literature24.

In order to solve this problem, a multidisciplinary medical consortium25 gathered in 2008 and decided that the term “laparoendoscopic single-site surgery” (also known as LESS surgery) most accurately depicted the surgical procedure in question. 22 For a more detailed description of this new type of resource, see Carvalho et al. (forthcoming). 23 Available at: http://www.fertstert.org/article/S00150282%2812%2900387-1/fulltext 24 See Box et al. (2008) , Gill et al. (2010), Autorino et al. (2011) , Rao et al. (2011), Sarkissian & Irwin (2013) , Mori (2014), Naitoh (2014). 25 Called the Laparoendoscopic Single-Site Surgery Consortium for Assessment and Research (LESSCAR), that published a consensus statement with the main conclusions of that meeting (Gill et al., 2010) .

Based on information provided by textual sources, some of which cited below, by the aforementioned video article and others on the same topic, as well as by the feedback from two senior expert gynecologists who are also surgeons, a concept modeling proposal based on <LESS surgery> was created using a software environment for concept system building called OTe (Ontoterminology engine) Soft, supported by ontoterminological principles (see Section 2.2.).

Designed by the Condillac research team26, this tool has a clear concept orientation, even though the user can also incorporate terms and, thus, the linguistic dimension. OTe Soft is structured around concepts, perceived as knowledge of a plurality of things that “help organize reality by grouping similar objects through what they have in common (Roche, 2015) (e.g. <Laparoscope>). One or more terms may be assigned to each concept, in various languages: i) natural (e.g. “laparoscope” (EN); “laparoscope” (FR); etc.; or ii) formal (e.g. programming language). In addition, a concept may be qualified by attributes, which have a given value, and be assigned one or more instances, also called “things”, i.e. representations of elements in reality (Check Figure 6).

Concepts are linked to each other via concept relations: subsumption (is_a) (generic) and composition (part_of) (partitive) are presented by default. However, the tool allows the user to create new concept relations, as long as the logical principles are maintained (e.g. two concepts cannot be linked by the instance of relation)27. These relations are represented by different colours, in order to facilitate the graph’s visual readability. The final “product” is called model, or semantic network, which can be exported in various formats (json, RDFS or OWL).

The following figures (4, 5 and 6) present examples of micro-concept maps built around the concept of <LESS surgery>: due to possible visual constraints, only partial views are shown here. The first micro-map (Figure 4) aims to po26 www.condillac.org 27 One of the challenges of creating a concept-modeling proposal lies, in fact, in defining other types of concept relations that do not fall under the generic or partitive categories. The ISO standards (1087-1:2000 and 704: 2009) lack diversity and systematisation, by classifying all the remaining relations as “non-hierarchical” (cf. Nuopponen 2011, 2014). sition <LESS surgery> within the broader concept of <Surgery>.

There is a first subdivision presenting <Open surgery> and <Minimally invasive surgery> as subordinate concepts of <Surgery>. In the latter subtype, the subsequent hierarchy-based modeling was constructed through specific differentiation, bearing in mind the Aristotelian definition of genus + differentia28: i) with/without external incision; ii) with one incision/with more than one incision. Besides other advantages, such as the operationalization potential mentioned before, this concept modeling strategy constitutes a valuable starting point for the terminologist in the construction of natural language definitions.

On the upper left side, the linguistic dimension is also visible, and it includes the terms associated to the <LESS surgery> concept. In this case, it was decided to list some of the synonyms of the concept identified in the literature: SingleIncision Laparoscopic Surgery – SILS; SingleSite Laparoscopy (SSL); Single-Port Access (SPA); Single-Port Laparoscopy (SPL). Although the image does not show that, the user has the possibility of navigating through the concept network via concepts, terms, or relations. The three images in Figure 4 were added afterwards, as the current version of the OTe Soft tool does 28 These, along with other Aristotelian categories, are explored in Porphyry’s Isagoge (2003). not yet allow the user to upload external resources (e.g. images, videos, diagrams, etc.)29.

Figure 5 explores the types of umbilical incisions that may occur in a LESS surgery, being that the single incision in the umbilicus (navel) is regarded by the expert community as the essential characteristic of the concept, i.e. the characteristic which makes the concept what it is and constitutes its essence (cf. ISO 1087-1: 2000). In this figure, the metaphoric use attributed to the <Omega incision> should also be emphasized.

Figure 6 contains a more detailed insight on the types of laparoscopes that exist, one of which - <Flexible video laparoscope> - is currently being used to perform LESS surgeries. In this case, the EndoEYE is presented as an instance of this concept. 29 This also applies to the images in the remaining figures.

There is also a basic distinction within the expert community between flexible and rigid laparoscopes, as depicted by the map. 5