current medicine research and practice 5 (2015) 168–171
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The [1_TD$IF]ethics of live demonstrations of surgery Vinay Kumaran [2_TD$IF]a,*, Samiran Nundy [3_TD$IF]b a b
Liver Transplant and HPB Surgery, Kokilaben [4_TD$IF]Dhirubhai Ambani Hospital, Mumbai, India [6_TD$IF]Sir Ganga Ram Hospital[7_TD$IF], Ganga Ram Institute of Medical Education and Research, New Delhi, India
Background: The use of live demonstrations of surgery and other invasive procedures has
Received 17 June 2015
become a popular teaching tool at medical conferences. However, concerns have been raised
Accepted 3 July 2015
that the interests of the patients participating in such events may be compromised.
Available online 1 August 2015
Material and [10_TD$IF]methods: We searched the PubMed database using the terms ‘‘live surgery[1_TD$IF],’’ ‘‘live surgical demonstration[12_TD$IF],’’ and ‘‘live procedure’’ and manually ﬁltered the results to select the
articles we considered to be most relevant. After reading 55 abstracts, we reviewed 36 full[13_TD$IF]-
text articles in detail. The relevant and non-repetitive information from these articles is
presented in this paper along with the authors' own opinions.
Results: In procedures with a low level of complexity, the complication rates do not seem to
be signiﬁcantly higher in patients participating in live workshops than when they are performed in a routine and familiar setting. However[14_TD$IF], the rate of successful completion
of the procedures is reported to be lower. In more difﬁcult operations there may be an unethical selection of 'suitable' patients and these may be followed by postoperative complications[15_TD$IF], some of them fatal, which are, understandably, not divulged to the conference participants. Many countries and societies[16_TD$IF], such as the American College of Surgeons, have banned the performance of live demonstrations of surgery. Conclusions: We suggest that there is sufﬁcient evidence that patients may be harmed when complex surgical procedures are performed in the context of live surgical workshops. The learning objectives may be met equally well by using video recordings of such operations. # 2015 Sir Ganga Ram Hospital. Published by Elsevier B.V. All rights reserved.
When one of us (Vinay [19_TD$IF]Kumaran) was a senior resident in general surgery, he attended a live surgical workshop on advanced hepatobiliary surgery. The workshop was organized at a well-known teaching hospital[20_TD$IF], which was one of the
pioneers in advanced hepatobiliary surgery. The invited surgeon was [21_TD$IF]internationally renowned for his hepatobiliary and liver transplant skills. He demonstrated an extended right hepatectomy for a hilar cholangiocarcinoma. It was a virtuoso performance. The surgeon stood on the left side of the patient so that the camera would have a good view. He lucidly explained the importance of a good lymph node dissection and
* [9_TD$IF]Corresponding author. Tel.: +91 9022932994. E-mail address: [email protected]
(V. Kumaran). http://dx.doi.org/10.1016/j.cmrp.2015.07.003 2352-0817/# 2015 Sir Ganga Ram Hospital. Published by Elsevier B.V. All rights reserved.
current medicine research and practice 5 (2015) 168–171
of resecting the caudate lobe of the liver. The operation was performed with minimal blood loss. The surgeon answered questions from the audience while operating. ‘‘I had already decided to specialize in gastrointestinal surgery but there is no doubt that the workshop did inﬂuence me to focus on hepatobiliary surgery and liver transplantation. To this day I perform extended right hepatectomy for hilar cholangiocarcinoma in the manner demonstrated that day. About 3 years later, I was doing my [2_TD$IF]MCh in gastrointestinal surgery at the same teaching hospital where this workshop was held and I saw the patient who had been operated then. He was alive and well with no evidence of recurrence[23_TD$IF].’’ This, perhaps, was the best[24_TD$IF]-case scenario and the aims of a live demonstration had been achieved – curing the patient and inspiring and teaching and inﬂuencing the subsequent practice of the watching surgeon. However[14_TD$IF], the results are not always the same. Recently, in a major city in India, there was an international conference on hepatobiliary and pancreatic surgery. A live demonstration of complex hepatobiliary surgery was one of the highlights of the conference. The invited surgeon was a well-known pancreatic surgeon from Europe who had been asked to perform a procedure on a patient who had a locally advanced carcinoma of the head of the pancreas. It was expected that he would need to perform a Whipple's procedure and resect and reconstruct a segment of the portal vein. Unfortunately, as the operation proceeded, it became clear to experienced hepatobiliary surgeons in the audience[25_TD$IF], the tumor was more advanced than was originally expected and was also involving the hepatic artery. The reasonable course of action, in a 'routine' setting, would be to abandon any attempt at resection and instead perform a bypass procedure with the option perhaps of reassessing resectability after neoadjuvant chemotherapy and/or radiotherapy. However, the surgeon, who clearly felt compelled to complete the demonstration of a resection and vascular reconstruction, proceeded to take out the [26_TD$IF]tumor when it was obvious to the audience that there would be residual tumor tissue. The surgeon reconstructed the hepatic artery as well as the portal vein and the blood loss was considerable. The outcome was never reported to the participants in the workshop but we later heard that the patient was re-explored for intra-abdominal bleeding and eventually died. These cases, while anecdotal, do raise questions about whether participation in live surgical workshops is harmful for the patient involved. The concerns raised are: 1. Does the patient have the undivided attention of the surgeon? Clearly, this may not make much difference if the operation is a simple one but it might be a factor in a complex procedure. The surgeon is called upon to answer questions from the audience, ensure a good view from the camera[27_TD$IF], and perhaps work with unfamiliar instruments in an unfamiliar operation [28_TD$IF]theater with unfamiliar anesthetists and assistants. 2. Is the decision-making process skewed? Clearly there is pressure on the surgeon and the organizers to demonstrate the operation in its entirety. The audience may be hoping that the operation turns out to be difﬁcult, partly because they want to see an expert dealing with tricky situations [29_TD$IF]
and partly because it improves the ‘‘spectacle[30_TD$IF].’’ The surgeon may feel pressured to undertake a resection in a situation where resection may not be the best option for the patient and the organizers may be pressured to list for resection a patient for whom other options may be better. 3. Is the optimal timing of surgery compromised? The organizers may delay the procedure so that cases are available for the demonstration or they may compromise on the pre-operative evaluation or preparation in order to have the patient ready by the date of the workshop. 4. Is the post-operative management compromised? If the surgeon is itinerant, the host institution may not be accustomed to managing patients undergoing the procedure in question. The question of responsibility and liability is also nebulous. While responsibility for the patient is generally understood to be with the host institution, it is clear that there is an element of a ‘‘it wasn't my fault’’ attitude on the surgeon's part when complications occur. [31_TD$IF]We discuss some of the available evidence on these issues.
We searched the [32_TD$IF]PubMed database using the terms ‘‘live surgery[1_TD$IF],’’ ‘‘live surgical demonstration[12_TD$IF],’’ and ‘‘live procedure’’ and manually ﬁltered them to select out the ones we considered most relevant. After reading 55 abstracts, we reviewed 36 full[13_TD$IF]-text articles in detail.
A large amount of the literature on live demonstrations comes from the ﬁelds of Urology and Gastroenterology. Many of their procedures are conducted endoscopically or laparoscopically [3_TD$IF] and are inherently suitable for live telecasting using the video feed from the camera. The procedures are also technically easier and more standardized than cardiovascular, surgical oncology[34_TD$IF], or hepatobiliary procedures. A patient undergoing an aortic aneurysm repair in a live demonstration in Japan in 2006 died.1 This led to considerable discussion and several bodies stopped the practice of live demonstration altogether. These included the American College of Surgeons and the American College of Obstetrics and Gynecology.2 Khan et al[35_TD$IF].2 report an anonymous survey of participants in the European Association of Robotic Urology Society Meeting in 2012. Of the 106 surgeons who responded, 98 had personal experience of performing live surgical broadcasts. Anxiety was reported by 6.5% when they were operating at home and by 19.4% while operating away from home. The quality of the procedure was perceived to be slightly worse by 16.1% of the surgeons and signiﬁcantly worse by 2.2%. When operating in an ‘‘away’’ situation, these ﬁgures increased to 23.9% and [36_TD$IF]3.3%, respectively. Most of the surgeons (62.4%) reported some anxiety or apprehension and 6.5% felt the level of anxiety was signiﬁcant. While most of the surgeons reported that their surgical performance was normal, 16.1% felt it was slightly worse and 2.2% felt it was signiﬁcantly worse when they were performing live.
current medicine research and practice 5 (2015) 168–171
In an internet-based survey conducted among members of the International Pediatric Endosurgery Group[37_TD$IF],3 which 61 surgeons and 148 delegates [38_TD$IF]completed, 83% of the surgeons agreed that stress levels were raised during live surgery demonstrations. Both surgeons and delegates agreed that live surgical demonstrations may be harmful to the patients. Thirty-six percent of the surgeons and 52% of the delegates stated that they would not consent to their own children being included in live surgical demonstrations. A large multicentre study from China was published in the American Journal of Gastroenterology in 2009.4 They compared patients who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) during live workshops in China from January 2002 to December 2007 with control patients admitted to the same unit for the same indication who received a therapeutic ERCP by an endoscopist with similar experience as those who performed the live demonstration. The complication rates were not signiﬁcantly higher in the live demonstrations (10.3% vs 8.6%) but the success rate was signiﬁcantly lower (94.1% vs 97.5%). A survey of [39_TD$IF]ophthalmologists from the UK was reported in 2008.5 Even in the genteel world of ophthalmology, respondents stated that voyeurism was one of the reasons for watching live surgery, [40_TD$IF]and some describing it as a ‘‘bloodsport’’ like watching ‘‘cock-ﬁghting[41_TD$IF],’’ ‘‘bull-ﬁghting,’’ or a ‘‘Formula 1 car crash[42_TD$IF].’’ There was a debate on the ethics of live operative workshops in the National Medical Journal of India in [43_TD$IF] 2003–2004 in which Ananthakrishnan described some nightmare scenarios witnessed by him in such spectacles. These included resection of a large hepatoma in the right lobe of the liver despite the presence of metastases in the left lobe and nibbling off a resectable periampullary carcinoma with a diathermy snare in order to demonstrate endoscopic biliary stenting.6 Nagral described a live operative workshop in which a leading surgeon from abroad was invited to demonstrate a liver resection.7 The patient selected had a huge liver [26_TD$IF]tumor. The surgeon, although ‘‘taken aback’’ by the size of the lesion, decided to proceed with the resection. He demonstrated a ‘‘quick and bloodless’’ technique[4_TD$IF], which involved clamping all the blood vessels of the liver and cutting through the liver with a knife. A few hours later[45_TD$IF], the patient bled massively and had to be re-operated by the local team as the ‘‘leading surgeon’’ had moved on to other commitments. The patient succumbed a few days later. Ardhanari wrote in [46_TD$IF]favor of live operating workshops stating that ‘‘there is no doubt that the adrenaline released while watching a live operation is what keeps an audience glued to their seats. Operating in a workshop is like playing a match on live television. Some perform well, others do not. Those who do not will surely stop. Even if they continue they are unlikely to be asked to operate again[47_TD$IF].’’8 Williams et al. refer to this phenomenon as ‘‘reality surgery’’ like ‘‘reality TV[48_TD$IF].’’9 They describe Dr John Cameron's account of viewing a live broadcast of a valve repair resulting in an unacceptable outcome because the surgeon did not want to acknowledge failure of the repair technique in front of an audience.
We have not described [49_TD$IF]all the articles in detail but found certain common threads running through them. These were: 1. Relatively simple procedures[50_TD$IF], such as ERCPs and endourology procedures[51_TD$IF], can be done safely. The rate of complications does not differ signiﬁcantly from that of patients undergoing similar procedures outside the live workshop system. 2. The success or completion rate of these procedures may be negatively impacted, particularly as the complexity of the procedure increases. 3. The physicians performing such procedures do feel an increased level of stress when doing so in front of a live audience. 4. Both performers and audience are aware that patients may be negatively impacted by participation in live-operative workshops but believe that the teaching beneﬁts to the audience outweigh the harm to the individual patient.
The live demonstration of a complex operation to an audience unfamiliar with the procedure undoubtedly has beneﬁts. Presumably, members of the audience who have not performed the procedure previously may now be able to do it and those who are already doing it may do so better after watching an expert. However[52_TD$IF], there are concerns that the patient participating in such a demonstration may be disadvantaged by the nature of the process. One of our concerns is that the pressure of performing a procedure in front of an audience may cause stress and impair the performance of the surgeon or physician. This may be further compounded if the demonstration is being held in an unfamiliar place with unfamiliar instruments, assistants[53_TD$IF], and anesthetists. Jet lag may further impair performance. These factors may not matter when the procedure is not challenging but become increasingly important as the complexity of the procedure increases. The need to interact with the audience and to answer questions may also prevent the surgeon concentrating on the procedure at hand. It is not possible to measure stress or performance objectively but the study reported by Liao et al[54_TD$IF]. from China4 suggests that while the complication rate of a relatively straightforward procedure like ERCP is not signiﬁcantly increased, the successful completion of the planned intervention is negatively impacted in the setting of live demonstrations. Data on more complex procedures [5_TD$IF]are not available, partly because they are less frequently performed [56_TD$IF]and there are anecdotal reports of poor outcomes due to the pressure of performing in front of a live audience.6,7,9 Internet[57_TD$IF]-based surveys of participants in live surgical demonstrations have shown that even surgeons who perform such demonstrations are sometimes willing to admit, anonymously, that their performance and the patient's outcome may be compromised in such a setting.2,3,5
current medicine research and practice 5 (2015) 168–171
Another concern is that the very process of participation in a live surgical demonstration may impair optimal decision[58_TD$IF]making for the patient. Surgery may be delayed or hurried, [59_TD$IF]and there may be pressure to perform a procedure[60_TD$IF], which is not indicated, examples of which are illustrated in the reports by Ananthakrishnan,6 Nagral[61_TD$IF],7 and Williams.9 It seems to us that all the objections to live-surgical demonstrations may be circumvented by showing an unedited video of the procedure in question. In this situation[62_TD$IF], the expert surgeon, performing the procedure in the familiar environment of his own operation [63_TD$IF]theater, is then free to take questions from the audience and discuss alternative options in a dispassionate manner. The outcome for the patient may also be disclosed to the participants at the end of the discussion. The only objection to this is Ardhanari's observation that it does not generate enough adrenaline and resembles watching a recording of a match rather than watching it live.8 I think most of us would be willing to forego the adrenaline rush in the best interests of the patient.
Participation in live surgical demonstrations has the potential to result in harm to the participating patients. The same learning objectives may be achieved by the use of edited or unedited videos of the surgeon operating in familiar [64_TD$IF] environments.
Conﬂicts of interest The authors have [65_TD$IF]none to declare.
1. http://www.japantimes.co.jp/news/2007/06/07/news/patientin-live-surgery-showing-died-soon-after/ [accessed 27.03.15]. 2. Khan SAA, Chang RTM, Ahmed K, et al. Live surgical education: a perspective from the surgeons who perform it. BJU Int. 2014;114:151–158. 3. Dingemann J, Laje P, St Peter SD, Ure BM. IPEG survery on live case demonstrations in pediatric surgery. J Laparoendosc Adv Surg Tech. 2012;22:705–709. 4. Liao Z, Li Z-S, Leung JW, et al. How safe and successful are live demonstrations of therapeutic ERCP? A large multicenter study. Am J Gastroenterol. 2009;104:47–52. 5. Hollick EJ, Allan BD. Liver surgery: national survey of United Kingdom ophthalmologists. J Cataract Refract Surg. 2008;34:1029–1032. 6. Ananthakrishnan N. The ethics of live operative workshops. Natl Med J India. 2003;16:340. 7. Nagral S. Live operative workshops: a critique. Natl Med J India. 2004;17:100–102. 8. Ardhanari R. In defence of live operative workshops. Natl Med J India. 2004;17:99–100. 9. Williams JB, Mathews R, D'Amico TA. ‘‘Reality surgery’’ – research ethics perspective on the live broadcast of surgical procedures. J Surg Educ. 2011;68:58–61.