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The oncological equivalence of laparoscopic and open rectal cancer resection was evaluated in four multicenter randomized controlled trials. The COLOR II and the COREAN trials demonstrated oncological equivalence; however, the ACOSOG and the ALaCaRT studies came to a different conclusion. In the latter two studies a composite endpoint that assessed the quality of the mesorectal specimen, the completeness of tumor-free circumferential and distal resection margins was chosen. In both trials a higher success rate for open surgery was shown; nevertheless, the validity of this composite endpoint has not been proven and no conclusions on solid oncological endpoints can be drawn. The COLOR II and the COREAN trial therefore remain the only available studies which investigated solid oncological endpoints, such as local recurrence and disease-free survival over an adequate follow-up time period of 3 years; however, the comparability of the study groups at least of the COLOR II trial needs to be called into question as only the experience of the laparoscopic surgeons was assessed. With a local recurrence rate of 5 % in both groups the oncological quality seems nevertheless to be good; therefore, a systematically inadequate control group should not be assumed. At this point it can be concluded that a good oncological outcome can be achieved with laparoscopic rectal resection in the hands of experts. For a final assessment the long-term results of the on-going trials needs to be awaited. If the promising results for laparoscopic surgery of the COLOR II trial are confirmed laparoscopic rectal resection should be preferred to open resection in the future. This conclusion is based on the generally known perioperative benefits of minimally invasive surgery.

Surgery can only maintain its role in a highly competitive environment if results are continuously improved, accompanied by further reduction of the interventional trauma for patients and with justifiable costs. Significant impulse to achieve this goal was expected from minimally invasive surgery and, in particular, robotic surgery; however, a real breakthrough has not yet been achieved. Accordingly, the new strategic approach of cognitive surgery is required to optimize the provision of surgical treatment. A full scale integration of all modules utilized in the operating room (OR) into a comprehensive network and the development of systems with technical cognition are needed to upgrade the current technical environment passively controlled by the surgeon into an active collaborative support system (surgery 4.0). Only then can the true potential of minimally invasive surgery and robotic surgery be exploited.

Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment "surgical operating room" has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.

Nowadays, increasing numbers of procedures jointly conducted by cardiac surgeons and cardiologists are performed as minimally invasive surgical procedures or interventions. Transcatheter aortic valve implantation, endovascular aortic aneurysm repair and a large variety of hybrid procedures for congenital heart disease have become current standards. Some of these hybrid procedures were shown to improve the therapeutic safety and efficacy, effects particularly true for high-risk patients and complex interventions. Hybrid procedures require indirect imaging, commonly provided by an angiography system in the hybrid operation theatre. This article describes the technical prerequisites required for a hybrid operation theatre as well as indications and rationales for hybrid procedures conducted in this environment. It is likely that the indications for cardiovascular hybrid procedures will continue to be expanded and that the hybrid operation theatre may become a laboratory for developing innovative approaches in the cardiovascular field. Therefore, the hybrid operation theatre will not only be the working environment for hybrid surgeons and interventionalists but also help to evolve their future.

Since June 2013 a hybrid operation theatre is used interdisciplinary in the department for surgery of Ulm University. In this operation theatre a floor-based flat panel c-arm, which is mounted on a robotic arm that can be controlled by the surgeon in a sterile environment, is linked to the operating table. Furthermore for the first time it was possible to integrate a navigation system in this setting. The interdisciplinary utilization (trauma, neurosurgery, cardiac and vascular surgery) makes this hybrid operation theatre very time and cost effective. In the orthopedic trauma department this system is mainly used for traumatic and oncologic pelvic and spinal injuries. In these anatomical regions the excellent image quality and large field of view of the robotic flat panel detector based 3D imaging combined with an intraoperative navigation system is a huge advantage. The system can also be used for complex fractures of the extremities. In the future there will be an integration of further imaging modalities and referenced holding devices in this setting.

Robotic assistance has the potential to compensate for the limitations inherent in standard laparoscopic surgery. The daVinci® surgical system remains the only currently available commercial robotic system. It has found popularity in rectal cancer surgery where its application has consistently been shown to reduce the need to convert to open surgery. With this exception, the technological advances of the robotic system have not so far translated into any reproducible patient benefit. The first part of this manuscript presents an overview of the current daVinci® platform, its applications, the evidence base and future developments in colorectal surgery. The second part of the manuscript looks at other robot systems in development and the different innovations and strategies taken to advance minimally invasive surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

Introduction: Inguinal hernia (IH) surgery has changed fundamentally during the last 25 years due to tension-free repair, minimally-invasive approaches and growing influence of economy in medical decision making. Aim of the study was the documentation and analysis of changes in IH surgery during the last 15 years in our patient cohort., Material and Methods: Patients undergoing elective or emergency inguinal/femoral hernia repair from January 1995 to December 2009 were included in the study. Analysis of patient data was carried out by prospective online recording., Results: A total of 1,908 patients with 2,124 IHs were treated in the study period and the number of IH repairs decreased continuously. The number of recurrent hernias peaked in 2005-2009 with 16.4%. The average preoperative hospital stay decreased from 2.4 to 0.4 days and the postoperative hospital stay from 7.0 to 3.3 days. The percentage of suture repairs declined from 54.9% in 1995 to 4.1% in 2009 and the percentage of open tension-free repairs rose to 52.9% in 1998. In the following years the majority of repairs were performed by minimally invasive procedures but in 2009 the percentage of conventional hernia repairs exceeded the rate of minimally invasive repairs., Conclusion: The main reason for these changes is the implementation of diagnosis-related groups which hampers inpatient repair of "simple" inguinal hernias, favors short hospital stay and does not adequately reimburse minimally invasive repairs.

Unlabelled: Increasingly complex techniques in cardiovascular medicine lead to a competitive partnership between cardiology and cardiac surgery. Common challenges will arise in the fields of coronary heart disease, heart valves, heart failure and rhythm therapy. For instance, coronary revascularization in acute myocardial infarction is no longer considered to exclusively be an interventional option. In comparison, the implantation of heart valves is increasingly carried out by cardiologists using interventional techniques. The latest designs of sutureless valves try to combine the benefits of conventional and transcatheter heart valves. Heart failure is the most common reason for hospital admission and thus an important therapeutic target for cardiology and cardiac surgery. New approaches in diagnostics, heart assist devices and cellular therapy meet this challenge., Conclusion: In the future only a sensitive and transparent collaboration across transsectoral borders will offer optimal therapy in cardiovascular medicine.

Cardiology and cardiothoracic surgery are closely related so that collaboration and communication are required to offer optimal therapy for patients. During the last decades many innovations have reduced the borders between cardiology and cardiothoracic surgery. Today, cardiologists may perform coronary interventions with good results that would have previously been the domain of coronary bypass surgery. In addition new valvular interventions have been developed, such as transfemoral or transapical aortic valve implantation and endovascular mitral valve reconstruction. New developments in cardiothoracic surgery have led to less invasive procedures and many surgical procedures can now be performed with minimally invasive techniques and without a cardiopulmonary bypass. To enable optimal therapy for patients, closer collaboration between cardiologists and cardiothoracic surgeons is required setting the stage for individualized therapy in the future.

Thoracic surgery is one of the self-contained surgical disciplines with an above average large potential over the next 20 years. An increase in mortality due to pulmonary diseases is to be expected worldwide. Bronchial carcinoma is the most common diagnosis in thoracic surgery patients and will remain a relevant topic for health politics for many years. However, the adequate treatment of these patients demands a high degree of interdisciplinary cooperation. In the future thoracic surgery will therefore be carried out in centres with an organ-dependent and interdisciplinary structure. From a surgical technical perspective minimally invasive operation strategies will become established for standard interventions, which are indispensible components of the repertoire for thoracic surgery. Thoracic surgery is traditionally a clinically oriented discipline with low academic superstructure and a high backlog demand in nearly all areas of research. It offers a large field of activity for the next scientifically interested generation with excellent chances to become established and succeed in this discipline with a very promising future.

The discipline of general and visceral surgery will change over the next 20 years due to technical and digital developments. Of particular significance will be computer-assisted surgery, pre-operative simulation and intra-operative navigation and also the further development of the minimally invasive technique itself, which overcomes the present limitations of complex visceral surgical resection and reconstruction and will replace open surgery in more and more fields. It is extremely probable that over the next 20 years surgeons will be dealing increasingly more with old patients and the spectrum of interventions will also change. Oncologic surgery will change due to the high dynamics in the development of new anti-cancer medications. Other fields, such as obesity surgery, will become more important. An irreversible development is the economization of the discipline and quality assurance. This will accelerate the development of high-volume centers for a large proportion of visceral surgical interventions.

The successful development of minimally invasive surgery would have been inconceivable without continuous advances in medical technology. The users, i.e. the surgeons, however, only accepted innovations with a clear-cut positive impact on clinical care. Accordingly, the expected exponential rise in costs could be avoided. The imbalance in cost/benefit aspects between the deliverers of medical care on one hand, and the patients, the insurance companies and the employers on the other is critical. In addition, further innovations are to be expected. This will not be possible without increasing costs, but there are good reasons to assume that expenses will rise only moderately. Each modern society is able (and obliged) to afford a certain amount of medical progress in order to maintain a high level of medical care and economic strength.