FUTURE DIRECTIONS

Future trends are toward less invasive surgery with shorter hospital stays, as evidenced in many surgical subspecialties. For instance, video-assisted muscle-sparing minithoracotomy for major lung resection has been used to decrease mean length of hospital stay for elderly patients to 1 day.^[174] Early extubation and critical pathways for accelerated discharge have been used with success in elderly patients undergoing isolated coronary artery bypass grafting. ^[175] Endovascular repair of abdominal aortic aneurysm is now being used in high-risk patients with good results.^[176] Laparoscopic surgical approaches have been shown to provide benefits to elderly patients in the form of smaller scars, decreased postoperative pain, and more rapid return to normal activity.^[177] In addition, there is a major thrust toward ambulatory surgery in the elderly. However, studies report that with ambulatory surgery, the elderly have higher rates of intraoperative events, in particular, events of a cardiovascular nature.^[178] The challenge of the future will be that of managing perioperative care of the elderly with their associated comorbid disease and increased risk in a cost-conscious environment.