Preparing Surgeons for the 21st Century

Medicine has caught up with the transformation of the Information Age. Surgeons are performing laparoscopic surgery, using endoscopically placed stents, diagnosing with noninvasive digital imaging, and monitoring patients with a myriad of sensors. Will the “hands” matter anymore? Are the large, extirpative resections yielding to noninvasive methods of detecting and ablating disease? What will the “tools” of surgeons of the twenty-first century be? Without question, surgeons will continue to perform some surgery with the traditional surgical instruments and the now-standard laparoscopic approach. But over the decades, newer technologies will have an increasing role. The trend seems to be one of minimally to noninvasive procedures, from direct, hands-on to indirect, hands-off (i.e., laparoscopic, catheter, and robotic-aided and computer-aided) approaches and from single modal (i.e., resection and reconstruction) to multimodal (i.e., biologically tagged, image guided, and dexterity enhanced) therapies. Also, surgical education will dramatically improve with Internet-based education, surgical simulation, and standardized metrics for the assessment of manual and technical skills. The physiologic basis of therapy is reaching down to the molecular and genetic levels while future reconstructive surgery will be with tissue engineering, organogenesis, or intelligent prostheses. Several fundamental changes are responsible for the genesis of the new surgical modalities. First is the revolution of the Information Age, with the application of these tools to health care generally and surgery specifically. As the Information Age infuses all of medicine, however, another more powerful revolution is beginning in the nonmedical arenas: the combining of the biological, physical, and information sciences into systems, which enhances performance beyond current limitations and turns current instruments, procedures, and processes from dumb to smart. For example, laparoscopic instruments will be multiarticulated like the human hand, using microelectromechanical systems (MEMS) devices with tactile feedback based on biologically inspired principles. Or totipotential cells, such as stem cells, will be genetically “programmed” to differentiate into specific tissue or organs and grown over a biological scaffold to create artificial tissues or organs. The bioengineering sciences to create these possibilities exist today in the laboratory but have not been moved into medical applications. This article looks at fundamental principles and basic science, identifies emerging medical applications, and extrapolates to the potential for new devices and procedures.