Open Surgery: What, Why, When, and Whom

The increasing aging population presents significant challenges and opportunities for modern surgical practice. With projections indicating a substantial rise in individuals aged 85 and older, surgical interventions in older adults, particularly frail individuals, are becoming increasingly critical. Minimally invasive surgery (MIS) has emerged as the gold standard for elderly patients due to its association with reduced postoperative pain, shorter hospital stays, and faster recovery. However, MIS presents unique challenges, such as prolonged operative times and complications related to hypercapnia and Trendelenburg positioning, particularly in frail patients and low-resource settings. Accurate patient selection and multidisciplinary geriatric assessments are essential for optimizing outcomes. In specific surgical contexts, such as hepatobiliopancreatic, colorectal, and gastric surgeries, evidence supports MIS over open approaches in most cases, although open surgery remains vital for managing complex conditions, emergencies, and patients with extensive comorbidities or anatomical constraints. Studies highlight the importance of balancing surgical risks with the benefits of interventions, emphasizing tailored approaches based on frailty, tumor characteristics, and institutional expertise. Despite advances in MIS techniques, open surgery retains a crucial role in modern practice, particularly for conditions requiring extensive resections, managing severe local inflammation, or achieving oncological safety. Future advancements in geriatric assessment tools and minimally invasive technologies, along with ongoing randomized controlled trials, are expected to refine surgical decision-making and improve outcomes for elderly patients undergoing major surgical procedures.