Expanding the horizons of surgical research: let us move towards P4 surgery

The nature, limitations and goals of surgical research are critical issues for the entire research community and represent a major global health challenge. This debate has long been struggling, but it is time to accelerate. The strong position of Sir Richard Horton, Editor-in-Chief of The Lancet, who in 1996 defined surgical research as a comic opera, served as an electric shock to most surgical researchers but had the undoubted effect of promoting qualitative research [1, 2]. In contrast to those days, large randomized controlled trials with well-defined end-points are now common in surgical research, and completed trials have demonstrated the benefit of certain procedures or the superiority of one technique or device over another, albeit in well-selected study populations with well-defined inclusion and exclusion criteria [2]: a recent trial comparing segmentectomy to lobectomy in small-sized peripheral non-small-cell lung cancer can be cited as an example [3]. Thus, several surgeons have joined the ‘club’ of evidence-based medicine advocates, and this can be considered a great achievement for the entire surgical community. In another recent Lancet article, surgeons were asked to continue their moulting and important issues were suggested, including access, equity and public health on the one hand and climate change requiring a reduction in the carbon footprint of operating theatres on the other [2]. Clearly, efforts should be made to improve inclusion and diversity in both surgical research and practice [2].