By Dr Menaka Sharma...
There was a time when surgery meant long incisions, heavy bleeding, and weeks of painful recovery. Surgeons depended on wide exposure to understand anatomy and control complications. Today, many of those same procedures are done through tiny ports, or sometimes without a single visible incision. In just a few decades, surgery has quietly transformed from an art of large, heroic cuts to a discipline of precision, optics, robotics, and intelligent assistance. This is the quiet revolution of modern surgery.
The Era of Open Surgery: The Original Standard
For more than a century, open surgery was the foundation of operative care. Techniques such as laparotomy, thoracotomy, and craniotomy allowed direct visualization and tactile feedback, fundamental for safe dissection and control of bleeding. Millions of lives were saved through open approaches, advancing trauma care, cancer surgery, and emergency interventions.
But the trade-offs were clear: long scars, significant post-operative pain, pulmonary complications, wound infections, prolonged bed rest, and extended hospital stays. Even with the introduction of antiseptics, anaesthesia, and antibiotics, large incisions meant significant physical trauma. Open surgery worked, but it worked at a cost.
Early Attempts at Minimally Invasive Surgery
The first attempts at minimally invasive procedures were limited- simple drainages, stone extractions, or diagnostic scopes. Surgeons wanted smaller wounds, but technology simply wasn’t ready. Early scopes lacked illumination, stability, and precision. Depth perception was poor, instruments were rigid, and safety was uncertain. Many procedures began with small incisions but converted to open surgery mid-way. Engineers and surgeons responded with better lenses, fibre-optic lighting, insulated instruments, and eventually video systems. Those incremental improvements set the stage for the breakthrough that followed.
The Laparoscopic Leap
The late 1980s changed surgery forever. When laparoscopic cholecystectomy proved feasible, the surgical world pivoted almost overnight. Using carbon dioxide to create space, fibre-optic cameras for visualization, and slender instruments for dissection and suturing, surgeons learned to operate inside the abdomen without opening it. The advantages were undeniable:
• Smaller incisions
• Less blood loss
• Reduced pain
• Shorter hospital stays
• Faster return to normal activity
Procedures that once required a week in a hospital now sent patients home in a day or two. Laparoscopy expanded rapidly—hernias, appendectomies, colectomies, bariatric surgery, gynaecological surgery , urology, and oncology.
But the transition was not effortless. Operating on a two-dimensional screen removed depth perception. The fulcrum effect reversed instrument movements. Tactile feedback disappeared. Training moved from textbooks to simulators, porcine labs, and supervised operative experience. The surgeon’s hands were no longer in the abdomen; the instruments were.
The message was clear: smaller cuts did not mean inferior surgery, just a different kind of skill.
The Robotic Renaissance
In the early 2000s, robotic systems entered the operating room, most famously the da Vinci platform. Surgeons sat at a console with magnified 3D vision, controlling robotic arms capable of wristed motion, tremor filtration, and sub-millimetre precision. What laparoscopy made possible, robotics made elegant.
Robotic surgery proved particularly valuable in confined spaces like the pelvis and chest. Complex suturing became easier. Visualization improved. Nerve-sparing accuracy increased in procedures such as prostatectomies and hysterectomies. Patient outcomes reflected fewer complications, shorter recovery, and improved function.
Of course, robotics came with challenges: high cost, specialized training, and longer initial operative times. But as experience grew, robotics moved from novelty to expectation. Young surgeons today are expected to be dual-trained in laparoscopy and robotics, because many procedures now use robotic platforms as the default approach.
Beyond Ports: NOTES and Advanced Endoscopy
Natural Orifice Transluminal Endoscopic Surgery (NOTES) pushed the boundary further by eliminating external scars altogether, avoiding injury to the abdominal wall. Early clinical work showed feasibility, though concerns remain about closure reliability and contamination. Still, the concept opened a new frontier. Flexible robotic endoscopes now allow biopsy, resection, cautery, and suturing from inside hollow organs. Procedures once considered purely diagnostic have become therapeutic.
The line between surgery and endoscopy continues to blur.
Smarter Eyes: Augmented and Image-Guided Surgery
Augmented reality and image-guidance are no longer science fiction. Surgeons can now superimpose CT or MRI maps onto the operative field, highlighting tumours, vessels, and nerves in real time. This technology has already improved accuracy in neurosurgery, spine surgery, hepatobiliary procedures, and oncology.
Instead of guessing where margins lie, surgeons can see them.
Artificial Intelligence in the Operating Room
AI is becoming the next major shift. Currently, AI systems assist through image recognition and workflow analysis in controlled research environments. Full autonomy remains distant—ethical responsibility, unpredictability of anatomy, and real-time decision-making are enormous challenges. For now, AI is a safety net, not a replacement.
The Surgeon Remains Central
Despite the advancements; from open to laparoscopic to robotic and AI-supported, one constant remains. Surgery depends on judgment. Technology amplifies skill; it does not substitute for it. The best outcomes still require anatomical knowledge, adaptability, situational awareness, ethical reasoning, and human intuition.
The surgeon of the future must be part clinician, part technologist, and part strategist.
The Revolution Continues
Surgery has evolved from large incisions to procedures that sometimes leave no external trace. Recovery times have shortened. Complications have decreased. Surgeons who once relied on their hands now rely on optics, consoles, and data.
This revolution didn’t arrive with fanfare. It arrived quietly, one smaller incision, one clearer camera, one smarter algorithm at a time.
And the transformation is still unfolding.
By Author
Dr Menaka Sharma
MBBS
IGGMC, Nagpur
Co- Author
Dr Danish Sheikh (Kaif)
MBBS, MS General Surgery