Yesterday a patient told me that, while living in the US, his earwax had been removed using ultrasound. The tech sounded odd for this purpose, so I asked to look into it again; the actual procedure was microaspiration. This is nothing more than what most ENTs do every day: cerumen removal under microscopic vision using suction. There is nothing particular about it, only the name, which has a tech aura for the patient.
Terminology in medicine is important. But, do we truly understand the concepts behind the words we use? This question becomes especially relevant at a time like this, when surgery is undergoing a profound transformation and will likely look very different in just a few years.
In the surgical documentation forms at the hospital, we are asked to mark the approach. The options are simple categories and this is a required checkbox: open, endoscopic, or other. This form was prepared with a certain lack of conceptual clarity.
What is, in fact, an endoscopic surgery? What do we mean by microsurgery? What exactly defines robotic surgery? And what do we really refer to when we say minimally invasive surgery? Any surgeon would be able to provide an answer. Yet many have not taken the time to reflect on these concepts in depth.
Consider a conventional tonsillectomy. It is neither an open nor an endoscopic procedure. It is, strictly speaking, a transorificial approach surgery. And yet we do not usually consider it minimally invasive. However, if we perform a radical tonsillectomy for cancer (through essentially the same approach), it may suddenly be perceived differently, and be considered minimally invasive surgery. Our definitions are often shaped by context rather than by consistent conceptual frameworks.
Something similar happens with microsurgery. A standard tonsillectomy could also be considered a microsurgical procedure if it is performed under magnification, whether with a microscope or surgical loupes (as I routinely do). In everyday hospital language, when we refer to “a micro,” we are usually talking about reconstructive surgery involving free flaps and microvascular anastomosis, typically in an oncological setting. In otolaryngology, the same term may also refer to laryngeal microsurgery (including transoral laser microsurgery).
At first glance, this may seem confusing. In reality, it becomes much clearer when we separate three fundamental elements:
- the procedure itself (e.g.. a tonsillectomy),
- the approach used to reach the target (e.g. transoral approach),
- and the instrumentation that allows us to perform the operation (both for vision and manipulation); the tools (e.g. surgical loupes end bipolar energy).
These are distinct dimensions, and conflating them is often the source of misunderstanding. Moreover when variable combinations of them define different surgical techniques (like TransOral Robotic Surgery, TORS, or Transoral Laser Microsurgery, TLM).
The idea of minimally invasive surgery (or minimal access surgery) is a good example of this confusion. It is not, strictly speaking, a technique. It is a principle, an attitude inherent to medical practice. It reflects the intention to minimize collateral damage to the patient adapting the approach in surgery. Every surgical act produces harm, at least in two ways: the damage caused by the procedure itself, and the damage caused by the approach we use to access the surgical field. The approach, in this sense, is simply the path we take to reach our objective. So usually we speak of minimally invasive approach (with minimally invasive referring to the approach, not to surgery itself).
The true revolution in minimally invasive surgery came with the development of endoscopy. The reason is straightforward: what we technically are able to do is highly dependent on our technological capabilities (adding to our surgical competence and expertise, of course). Endoscopy dramatically changed how we operate across many anatomical regions. It allowed not only percutaneous access, but also the expansion of transorificial approaches (transoral, transnasal, transanal, transvaginal, transureteral…), reducing the morbidity associated with surgical access while broadening our possibilities.
Robotic surgery most significant contribution is perhaps the introduction of surgery into the digital ecosystem.
Robotic surgery represents a further step in this evolution. It did not simply refine endoscopic techniques; it transformed the framework in which surgery operates. Robotics enhances precision, visualization, and ergonomics, but its most significant contribution is perhaps the introduction of surgery into the digital ecosystem. This creates the conditions for integration with data systems, advanced imaging, artificial intelligence, and, eventually, autonomous surgical platforms.
However, it is essential to understand that not all robotic surgery is endoscopic. Even in soft tissue robotic surgery, this is not always the case. Systems such as Symani are used for robotic microsurgery (more precisely, robotic supermicrosurgery). No endoscope involved. Robotic platforms in orthopedics also operate under entirely different principles.
Ear surgery provides a good illustration of how these concepts overlap. Much of it is transorificial, performed through the external auditory canal. Historically all of it is microsurgical (due to the need for magnification), although Increasingly, some of it is endoscopic. And now, for selected procedures we are witnessing a gradual incorporation of robotic instrumentation. These are not competing definitions, but complementary ones.
For practical purposes, it is helpful to keep a few core definitions in mind.
- A minimally invasive approach is one designed to reduce access-related damage, often through percutaneous or transorificial routes.
- Microsurgery refers to procedures performed with optical magnification.
- Endoscopic surgery relies on endoscopes for visualization.
- Laser surgery is defined by the use of laser as a primary instrument.
- Robotic surgery involves the use of robotic systems to assist or perform surgical tasks.
From there, combinations are not only possible but increasingly common. Modern surgery frequently integrates multiple dimensions at once: endoscopic and robotic, microsurgical and robotic, transoral robotic and laser-assisted, among many others.
Surgical practice will be reshaped by technological advances at an unprecedented pace.
We are entering a period in which surgical practice will be reshaped by technological advances at an unprecedented pace. Without a clear understanding of the principles we risk confusing innovation with complexity, and progress with novelty. In the years ahead, those who adapt best will not necessarily be those who adopt every new technology first, but those who understand exactly what they are doing, how they are doing it, and, above all, why.
J Granell. April 18, 2026.