From lobotomy to connectomics: a critical review of contemporary psychosurgery

Contemporary psychosurgery is increasingly regarded less as an invasive surgical discipline and more as a circuit-based medicine. This narrative critical review traces the evolution from the extensive frontal lesions of the early twentieth century to contemporary techniques, in which focal ablation and reversible neuromodulation form part of a shared therapeutic armamentarium. Building on the classical history-from trephinations and lobotomies to stereotaxy-we outline a functional neuroanatomical framework that integrates thelimbic system, basal ganglia, prefrontal cortex, and monoaminergic systems, conceptualized as networks in which emotional and cognitive symptoms are generated and maintained. We then introduce the foundations of connectomics (diffusion tensor imaging, functional MRI, and graph-theoretical models) and their contributions to redefining targets not as isolated points but as nodes within fronto-limbic networks implicated in psychopathology. On this substrate, we review the main contemporary techniques: ablative approaches (radiofrequency, radiosurgery, laser ablation, focused ultrasound) and stimulation-based interventions (deep brain stimulation, vagus nerve stimulation, cortical stimulation, and transcranial magnetic stimulation), emphasizing their mechanisms, advantages, and limitations. The core of the article is an indication and circuit-based synthesis of evidence in obsessive- compulsive disorder, treatment-resistant major depression, and other selected conditions (eating disorders, addictions, Tourette syndrome, aggression, schizophrenia, and post-traumatic stress disorder), with particular attention to candidate profiles, clinical outcomes, and integration with psychotherapeutic and pharmacological strategies. We subsequently explore how these developments may converge into a model of precision psychiatry built around symptom dimensions, connectomic-guided targeting, biomarker-informed decision-making, and adaptive stimulation, while also considering the major ethical and organizational issues they raise. Overall, we propose understanding contemporary psychosurgery as a network-based, gradual, and multimodal intervention intended for carefully selected subgroups of treatment- refractory patients whose core symptom clusters might be linked to potentially modifiable white-matter hubs.