Multiaccess Surgery

Gone are the days of a surgical therapy with a single surgical approach: open surgery. Today many diseases may be treated by any number of procedures. For example, esophageal tumors can be treated by open surgical resection, minimally access (laparoscopic) surgery, image-guided ablation (cryo-, thermal-, radio-frequency), noninvasive destruction (transcutaneous high-intensity focused ultrasound, or HIFU), endovas-cular embolization, or by endoluminal (endoscopic) ablation and/or stenting. A number of diseases are best treated by dual or multiple modalities—combinations of minimally invasive and hand-assisted, endoluminal, laparoscopic, and so on. Such approaches, usually reserved for complicated diseases, will also require a pre-operative planning session, using three-dimensional virtual reconstruction of the patient-specific anatomy from CT, MRI, or other modalities. While the results using such a preplanning process have unequivocally shown increase precision and decrease operative time for liver [3], plastic, craniofacial [4], neurosurgery, and other procedures, there is significant time devoted to the preoperative planning and rehearsal process for which there is currently no reimbursement. Eventually such a process will become routine for most complicated surgical cases; however, it is uncertain whether all procedures will be either planned or rehearsed ahead of time.

The busy practicing surgeon must strive to keep abreast of the new competing technologies and become trained and facile with as many approaches as is reasonable. An awareness of this multiple access trend must be monitored, for it may well impact, through regulation, how surgical practice may be conducted. It is conceivable that decades from now, surgeons will be required to rehearse all surgical procedures on the patient's three-dimensional reconstructed anatomy before being allowed to operate on that patient.

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