Disruptive visions: biosurgery

There are a number of new therapeutic options generated by the biotechnology, bioengineering, and bioimaging revolutions in terms of organ-specific designer drugs, genetically engineered cells, cell-specific proteins and drugs, directed energy instruments, therapeutic microdevices, etc. Many of these new therapies need to be placed exactly on, within, or adjacent to an organ, and many others are delivered by endoluminal or endovascular approaches. The common requirements are (1) the accurate delivery of the modality and (2) the functional importance of targeting the biologic basis rather than the anatomic structure--hence the term biosurgery. As more of these therapies achieve clinical applicability and FDA approval, there will be the need for the precision of delivery to be at the micro- and nanoscale, which is well beyond human physical limitations. The surgeon of the future must be able to identify those therapeutic modalities that would benefit from such exact placement or implantation and acquire the skills, training, and equipment to use surgical expertise to deliver these new modalities. A review of some of the emerging opportunities is presented. Ignoring these challenges will relinquish these new procedures to other nonsurgical interventionalists, perhaps to the detriment of patient safety.