The reform of medical concepts,development of medical knowledge and innovation of medical techniques bring surgeons from the era of soldering iron to the digital era.In the 21st century,the demand for an excellent surgeon goes beyond by adding minimal invasiveness and optinal recovery of patients.With modern technology,we could obtain the information of external presentations as well as the internal relationship of organs by three dimensional reconstructions.With virtual technologies and robotic surgical systems,preoperative surgery planning and remote control of surgery could be realized currently.These changes are not only the reformation of minimally invasive surgcry,but also the trends of development of surgery in the 21st century.

Bile duct has great attraction to surgeons due to its special anatomical location,unique biological features and origin of complicate diseases. Minimally invasive surgery,represented by laparoscopic cholecystectomy and Davinci robotic surgical system,has brought technic revolutions to traditional biliary surgery.In order to understand the prospect and regression of biliary surgery in the new era,we need to upgrade the knowledge of the biliary system,and systemically investigate the anatomy and development of bile duct. The study of biliary system should follow the path of extrahepatic system to hilar and then to the intrahepatic system,and the intrahepatic biliary disease should be emphasised in this new era.

Hilar cholangiocarcinoma has received great attention in the past 25 years because of its rising prevalence. However, the results of surgical treatment of hilar cholangiocar-cinoma are still unsatisfactory. A series of studies on cholangio-carcinoma, both clinical and experimental, were conducted in the Research Institute of Hepatobiliary Surgery of PLA. Detailed clinicopathological research revealed the characteristics of nerve involvement and metastasis of bile duct cancer, which may be responsible for the high recurrence after surgical removal. Hepa-titis C virus may be one of the causal factors of bile duct cancer in China. Clinically, of the 402 patients with hilar cholangiocarcinoma, 51. 5% of the resections were found to be R0. The 5-year survival rate was 33. 3% and the morality rate was 0.3%. For those high-risk patients with jaundice, when resec-tion of the hepatic artery was found to be necessary, an arterial-portal venous shunt was constructed with satisfactory results. However, the best approach to treat hilar cholangiocarcinoma still needs further investigation.

Liver,a large solid organ in the body,had long been the"forbidden"place to surgeons until the 1950s when the structure of liver wag thoroughly studied.Surgery Was the only choice of treatment of liver cancer at that time,and regular hepatectomies carried a rather high morbidity and mortality rate.As the result of refinement of surgical technique and the advancement of science and technology,the operative mortality rate of liver resection at the 1980s was lowered to around 10%.At the beginning of the 21 st century,series of liver resections with no operative death have been reported.In a consecutive 2008 csses of liver resection which were carried out at General Hospital of PLA from 1986 to 2005.the perioperative mortality rate was 0.45%(9/2008).Surgery is not the only modality in the treatment of liver cancer at present,especially for early liver cancer with a tumor size of less than 3 ca in diameter.However,the prevention of postoperative recurrence and metastasis is still a big challenge to surgeons.

General surgery has been the clinical foundation for all of the branches of the surgical specialties.The scientific principles developed in general surgery have spread through the specialties as well.This is the basis for surgical mastery.The rapid development of information sciences brings great opportunities for further developments in general surgery.General surgeons will be challenged to learn how to incorporate these advances into their practice.Integrating other disciplines such as digital imaging will be required for general surgeons in the 21st century.General surgeons should not only understand the essence of traditional general surgery,but also be proficient in the usage of advanced diagnostic and therapeutic tools which will lead to promoting further developments in general surgery.

Hilar cholangiocarcinoma (HCCA) occurs at the confluence of the right and left hepatic bile ducts.Because of the unique anatomical position and the biological behaviour of HCCA,hepatic vessels,nerves,lymph nodes and adjacent tissues are easily invaded by HCCA.The operation for HCCA is difficult,and the prognosis of patients is poor.Extended hepatectomy guided by imaging techniques shed light on the management of HCCA,while controversies on extended hepatectomy exist at home and abroad,and a standard treatment is needed to be formulated.Therefore,the surgical management for HCCA should be standardized for improving the radical resection rate,reducing the incidence of complications and mortality.

Despite the recent improvement in the surgical treatment of hepatolithiasis, inadquate correction of the concommitant biliary tract stricture remains to be the major factor of therapeutic failure. Proper managements of both the stone and the stricture are two inseparable aspects of a problem. But today doctors are still in need of a series of effective operative procedures to accomplish this purpose.This paper is to report a retrospective study of 464 cases of hepatolithiasis surgically treated during a period from 1963 to 1981 in order to evaluate the different operative methods used in this institute on the basis of their long-term results. Internal entero-biliary drainage is considered as a major approach in the surgical treatment of hepatolithiasis. But the result of choledochoduodenostomy is far from satisfactory since it brings about a lot of serious sequalae, some of which are even disastrous. Many a patient requires opening of the anastomosis and is reoperated on according to the existed condition. It seems essential that the indication of choledochoduolienostomy should be restricted to a few carefully selected patients.To those late cases complicated with portal hypertension, staged operation has proved to be imperative. 11 out of the 14 late cases were saved since all of them underwent a meso-caval shunt before the operation on the hepatic lesion was performed. 2 of 3 deceased cases in this group were those without a preliminary shunt.The most difficult problem in the treatment of hepatolithiasis at present is the right lobe lesions especially those involving the second-order branches of hepatic duct. Several operative procedures the author used to manage this condition were introduced and discussed.

Since the success of the first case of laparoscopic cholecystectomy in 1987,minimally invasive surgery has become the most active field in all the branches of surgery.The traditional concept of surgery needs to be changed as the rapid development of surgical procedures,medical materials and devices,and the requirement of biopsychosocial model of medicine also poses great challenges to today's surgeons.Traditionally trained surgeons may find it difficult to adapt to the new developments.While,on the other hand,young laparoscopists may be at a loss when facing the difficulties encountered during the laparoscopic operation.The surgeons of tomorrow should have profound base of the knowledge of surgery and skillful in laparoscopy at the same time.

Traumatic biliary stricture,usually iatrogenic during biliary surgeries,is still a disastrous mistake because of its serious consequences.As the rapid development of hepatic surgery and liver transplantation and widespread use of laparoscopic cholecystectomy,patterns of traumatic biliary stricture changes in result as more complicated.In the future,more will be expected from the changes of the view point that the biliary system is actually an organ rather than merely an excretory duct,and,further more,the preservation of integrity of physiological function of the biliary tract should be considered during surgical repair.A simplified classification of bile duct injuries and biliary stricture is presented for discussion.

Surgery is a kind of medical practice to cure patients by operative interventions.The history of surgery was as long as the history of human civilization.To treat diseases with conventional surgical methods,patients often suffered from great pain both physically and mentally,besides the everlasting unsightly scar.Since the introduction of laparoscopic surgery in 1987, enthusiasm for minimally invasive surgery has been surging with great rapidity.There were discussions about the true connotation of minimally invasive surgery over the country.Trauma, both from accidental injuries or inflicted by surgical operations,if reaches to a certain magnitude,is a kind of noxious stumulus,which disrupts the homeostasis of the organism.This stress condition sets up a net work of adaptation reaction in the body, which if over expressed or underresponded,would do harm to the organism.Therefore,in considering the effect of minimally invasive surgery,not only the length of the surgical incision made,but also the systemic response of the body,should be our concern.Response to trauma is a heritage of our ancestor.With the rapid development of science and technology today, it might be possible for us to modify it so that its deleterious effects are minimized.Therefore, minimally invasive surgery,and to minimize the traumatic effect of conventional surgery,both locally and systemically,will be the main trend of surgical modalities in the 21st century.