Most of the discussion has focused upon variations on established surgical practices using instruments that are a modification of current surgical tools. There are a number of new technologies that are fundamentally different. One class of technologies is the energy-directed systems, which include some ablation technologies in use today, such as radiofrequency (RF), thermal (cryo or heat), laser, as well as those used by radiologists such as X-ray, proton beam, etc. A significant difference between radiological and surgical use of energy systems (X-ray, proton beam, etc.) is that radiologists usually discharge X-rays over large areas to kill massive amounts of tissue, whereas the surgical energy tools are used with precision (and usually hand held) for very specific localized effect. There are other parts of the electromagnetic spectrum that are being investigated as potential energy-directed surgical tools: microwave, millimeter wave, femtosecond lasers, HIFU , photodynamic, and photoinduction therapy. What all these have in common is that they replace the conventional mechanical instruments of scalpel, clamp, and stapler with precisely directed energy. Although some of these new technologies are handheld instruments, the majority of these energy-directed tools are (and will be) controlled with robotic systems to provide accuracy and safety.
A second class of unconventional surgical instrument is the micro- and nanoscale systems (microsystems are a thousand times smaller and nanosystems are a million times smaller than are current instruments). Like energy-directed systems and because of their small size, micro- and nanoscaled systems must be computer controlled. Some simple microsystems are being used for ophthalmology, otolaryngology, plastic, and neurological surgery, the most commonly employed is LASIK surgery. The experimentation now is on creating entire machines on a microscopic level: for microscale there are the microelectromechanical systems (MEMS), which are etched from silicon wafers, and for nanoscale there are assemblies of molecules into specific configurations to produce tiny machines that can enter the blood stream and cells. At the time of this writing, demonstration nanoengines have been created but not designed specifically for any medical application—in essence, proof of concept. How far these systems will proceed to the vision of miniature machines traveling through the body and blood stream as depicted in Isaac Asimov's The Fantastic Voyage  is yet to be seen.
The impact of these unconventional new technologies is not predictable, because their use signals a complete disruption in the practice of surgery. This change is best characterized as follows. Current surgical technologies are used to resect, remove, replace, and repair organs and tissues—structure and anatomy; the unconventional technologies will be implemented at the cellular and molecular levels—changing the basic biology (and possibly DNA itself) without changing the anatomy but inducing the repair at a biologic level. Hence the term biosurgery has been applied to indicate this fundamental change . The challenges to practicing surgeons are even greater, since it will be necessary to keep abreast of advances not only in the practice of surgery, but also for the basic sciences of biology, engineering, and informatics, a monumental task.
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