NEWS & VIEWS SURGERY
Matthew Brown and Prokar Dasgupta
Concerns have been raised regarding the educational value of live surgical events (LSEs) and whether such events compromise patient safety. Now, the European Association of Urology has published a Live Surgery Policy Statement, aimed at protecting patient safety and ensuring that LSEs are conducted in an ethical and accountable manner. Brown, M. & Dasgupta, P. Nat. Rev. Urol. 11, 249–250 (2014); published online 8 April 2014; doi:10.1038/nrurol.2014.75
The demonstration of surgical techniques to an audience is a concept as old as surgery itself. However, the evolution of telemedicine and minimally invasive surgery has facili tated a rapid expansion in live operating at surgical meetings. In an era of multimedia journals and an increasing trend towards surgical simulation, some senior surgeons question the place of live surgical events (LSEs) in surgical education.1 However, much knowledge can be gained by an audi ence closely observing an experienced sur geon handling unexpected intraoperative issues and, with LSEs, procedures can be examined and peer reviewed in a manner that is simply not possible with edited video clips. Unsurprisingly, in a 2010 survey of 271 participants at an interventional vascu lar meeting, 82% felt live cases had a greater educational value than recorded video.2–4 While recognizing the educational merit of LSEs, the European Association of Urology (EAU) also acknowledges the concerns of the wider community, and has now pub lished a policy on live surgery, which stipu lates that the educational value of all LSEs must be justified in a formal application to the EAU LSE committee.5 It has further been suggested that case selection for LSEs is subject to bias from commercial interests, self-promotion, and an ‘indication creep’, whereby host insti tutions inappropriately select patients for an upcoming event.6 In a survey of urolo gists performing live surgery in the USA, concerns about the indication for the LSE were reported “often” (43.9%) and “always” (13.4%).2 The EAU shares these concerns and recommends that the guest surgeon for
each LSE should be briefed on all patient data “well ahead” of time, and that they reserve the right to decline an LSE. The EAU policy also indicates that commercial interests need to be declared and the choice of guest surgeon is subject to institutional and directorate approval.
‘‘
Future versions of the policy might also include a pre-LSE audit of the guest surgeon’s case numbers…
’’
Nonetheless, concerns about patient safety present the greatest threat to the future of LSEs. An increased anaesthesia time, higher infection rate, and higher complication rate from live surgery have been suggested. 2 These issues have led numerous specialist societies (including the EAU and AUA) to critically evaluate the role of live surgery or, in some cases, ban it altogether.2 However, some comparative data indicate that the results and complica tion rates achieved with properly conducted LSEs performed by experienced surgeons at established centres are no different to those associated with elective procedures.7 Indisputably, LSEs can disrupt operating schedules8 and extend the duration of pro cedures, as the surgeon attempts to simul taneously concentrate on the patient and engage with the audience.4 Schmidt and col leagues9 reported an average delay of 9 days in 10% of patients enrolled in endoscopic live surgery workshops. Moreover, guest surgeons might be placed under additional time pressures, increasing the likelihood
NATURE REVIEWS | UROLOGY
XiXinXing/iStock/Thinkstock
Protecting patients during live urological surgery
that they will take shortcuts and unneces sary risks. To protect the patient from any detrimental effects that arise from logisti cal issues, the LSE moderator (who serves as the link between surgeon and audience), and the independent patient advocate (a new concept) are key.6 The EAU policy dictates that patient care should not be unduly delayed, and the patient advocate should be in attendance to ensure the patient’s interests, dignity, anon ymity, and confidentiality are safeguarded. If the independent advocate perceives that there are any imminent or actual breaches of conduct, they can stop the live surgery transmission at any time. Broadcasting a surgical procedure irrefu tably produces a unique set of conditions and challenges that might affect an indivi dual surgeon’s performance. 6 Stress and fatigue can impair cognitive and motor function, and concentration can be dis rupted by interjections from the moderator or a lack of familiarity with the host surgi cal team. In a survey of leading academic urologists in the USA, anxiety levels were reported to be “high” (25%) or “very high” (17%) during LSE; these levels are signifi cantly higher than those associated with performing the same procedures at home institutions (“high” and “very high” in 9% and 8.9% of cases, respectively).2 Given the potential demands placed on a surgeon during LSE, the EAU stipulates that a “live surgery director” should be appointed for each event. This senior clinician should be responsible for coordinating the entire process and selecting the guest surgeon. Perhaps the EAU policy should also expli citly state that the guest surgeon must be VOLUME 11 | MAY 2014
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS highly experienced in the chosen procedure and have a proven track record of teach ing and operating under pressure. Future versions of the policy might also include a pre-LSE audit of the guest surgeon’s case numbers and results. A more important shortfall of the EAU policy is that it does not emphasize surgi cal rehearsal. A full rehearsal prior to the LSE could lead to improved performance on the day.10 In particular, the guest surgeon and host team should be introduced, roles should be clarified, the timing of anaesthesia, surgical start, and uplink must be agreed, positioning and specific requirements of the case should be checked, and all clinical concerns should be discussed before the day. The moderators could also prepare the guest surgeon for likely questions, and parameters for ceasing broadcast should be set (for example, running over time or excessive blood loss).4 Finally, the EAU policy prescribes rigor ous postoperative care and mandates the reporting of complications through the EAU web-based Live Surgery Registry (set up 2 years ago). This thorough approach should reassure critics that LSEs are being conducted in an ethical and transparent manner, and that complication rates are being audited carefully by this professional body.
MAY 2014 | VOLUME 11
In summary, the EAU policy statement on live surgery is an admirable effort to safe guard patients while preserving the concept of live surgery for the future. The EAU will regularly revisit and refine the policy statement, and there are areas of potential improvement in relation to surgical rehearsal and the provision of selection guidelines for guest surgeons. Urology, Level 1, Southwark Wing (M.B.), MRC Centre for Transplantation, NIHR Biomedical Research Centre, Kings College (P.D.), Guys Hospital, Great Maze Pond Road, London SE1 9RT, UK. Correspondence to: P.D. [email protected] Acknowledgements P.D. acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. He also acknowledges the support of the MRC Centre for Transplantation and grants from the Guy’s and St Thomas’ Charity, EU‑FP7, The Urology Foundation, The School of Surgery, Olympus, Heathside Trust and The Vattikuti Foundation. M.B. holds a Robotic Fellowship at Guy’s, which is supported by educational grant funding from Intuitive Surgical and The London Deanery. Competing interests The authors declare no competing interests.
1.
Toouli, J. What is the role of “live surgical demonstrations” at conferences? HPB (Oxford) 8, 163–164 (2006). 2. Duty, B., Okhunov, Z., Friedlander, J., Okeke, Z. & Smith, A. Live surgical demonstrations: an old, but increasingly controversial practice. Urology 79, 1185.e7–1185.e11 (2012). 3. Sugarman, J., Taylor, H., Jaff, M. R. & Sullivan, T. M. Live case demonstrations: attitudes and ethical implications for practice. Ann. Vasc. Surg. 25, 867–872 (2011). 4. Challacombe, B., Weston, R., Coughlin, G., Murphy, D. & Dasgupta, P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int. 106, 1571–1574 (2010). 5. Artibani, W. et al. EAU Policy on Live Surgery Events. Eur. Urol. http://dx.doi.org/10.1016/ j.eururo.2014.01.028. 6. Kallmes, D. F. et al. Live case demonstrations: patient safety, ethics, consent, and conflicts. Lancet 377, 1539–1541 (2011). 7. Devière, J. et al. Recommendations of the ESGE Workshop on Ethical-Legal Issues Concerning Live Demonstrations in Digestive Endoscopy. First European Symposium on Ethics in Gastroenterology and Digestive Endoscopy, Kos, Greece, June 2003. Endoscopy 35, 765–767 (2003). 8. Guillonneau, B. Live surgical demonstration: is it worthwhile? Nat. Clin. Pract. Urol. 4, 59 (2007). 9. Schmit, A. et al. Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations. Endoscopy 37, 695–699 (2005). 10. Hamilton, L. et al. Seminar Report. The Royal College of Surgeons [online], http:// www.rcseng.ac.uk/policy/policy-seminars/ live-surgery/seminar-report (2014).
www.nature.com/nrurol © 2014 Macmillan Publishers Limited. All rights reserved
Matthew Brown and Prokar Dasgupta
Concerns have been raised regarding the educational value of live surgical events (LSEs) and whether such events compromise patient safety. Now, the European Association of Urology has published a Live Surgery Policy Statement, aimed at protecting patient safety and ensuring that LSEs are conducted in an ethical and accountable manner. Brown, M. & Dasgupta, P. Nat. Rev. Urol. 11, 249–250 (2014); published online 8 April 2014; doi:10.1038/nrurol.2014.75
The demonstration of surgical techniques to an audience is a concept as old as surgery itself. However, the evolution of telemedicine and minimally invasive surgery has facili tated a rapid expansion in live operating at surgical meetings. In an era of multimedia journals and an increasing trend towards surgical simulation, some senior surgeons question the place of live surgical events (LSEs) in surgical education.1 However, much knowledge can be gained by an audi ence closely observing an experienced sur geon handling unexpected intraoperative issues and, with LSEs, procedures can be examined and peer reviewed in a manner that is simply not possible with edited video clips. Unsurprisingly, in a 2010 survey of 271 participants at an interventional vascu lar meeting, 82% felt live cases had a greater educational value than recorded video.2–4 While recognizing the educational merit of LSEs, the European Association of Urology (EAU) also acknowledges the concerns of the wider community, and has now pub lished a policy on live surgery, which stipu lates that the educational value of all LSEs must be justified in a formal application to the EAU LSE committee.5 It has further been suggested that case selection for LSEs is subject to bias from commercial interests, self-promotion, and an ‘indication creep’, whereby host insti tutions inappropriately select patients for an upcoming event.6 In a survey of urolo gists performing live surgery in the USA, concerns about the indication for the LSE were reported “often” (43.9%) and “always” (13.4%).2 The EAU shares these concerns and recommends that the guest surgeon for
each LSE should be briefed on all patient data “well ahead” of time, and that they reserve the right to decline an LSE. The EAU policy also indicates that commercial interests need to be declared and the choice of guest surgeon is subject to institutional and directorate approval.
‘‘
Future versions of the policy might also include a pre-LSE audit of the guest surgeon’s case numbers…
’’
Nonetheless, concerns about patient safety present the greatest threat to the future of LSEs. An increased anaesthesia time, higher infection rate, and higher complication rate from live surgery have been suggested. 2 These issues have led numerous specialist societies (including the EAU and AUA) to critically evaluate the role of live surgery or, in some cases, ban it altogether.2 However, some comparative data indicate that the results and complica tion rates achieved with properly conducted LSEs performed by experienced surgeons at established centres are no different to those associated with elective procedures.7 Indisputably, LSEs can disrupt operating schedules8 and extend the duration of pro cedures, as the surgeon attempts to simul taneously concentrate on the patient and engage with the audience.4 Schmidt and col leagues9 reported an average delay of 9 days in 10% of patients enrolled in endoscopic live surgery workshops. Moreover, guest surgeons might be placed under additional time pressures, increasing the likelihood
NATURE REVIEWS | UROLOGY
XiXinXing/iStock/Thinkstock
Protecting patients during live urological surgery
that they will take shortcuts and unneces sary risks. To protect the patient from any detrimental effects that arise from logisti cal issues, the LSE moderator (who serves as the link between surgeon and audience), and the independent patient advocate (a new concept) are key.6 The EAU policy dictates that patient care should not be unduly delayed, and the patient advocate should be in attendance to ensure the patient’s interests, dignity, anon ymity, and confidentiality are safeguarded. If the independent advocate perceives that there are any imminent or actual breaches of conduct, they can stop the live surgery transmission at any time. Broadcasting a surgical procedure irrefu tably produces a unique set of conditions and challenges that might affect an indivi dual surgeon’s performance. 6 Stress and fatigue can impair cognitive and motor function, and concentration can be dis rupted by interjections from the moderator or a lack of familiarity with the host surgi cal team. In a survey of leading academic urologists in the USA, anxiety levels were reported to be “high” (25%) or “very high” (17%) during LSE; these levels are signifi cantly higher than those associated with performing the same procedures at home institutions (“high” and “very high” in 9% and 8.9% of cases, respectively).2 Given the potential demands placed on a surgeon during LSE, the EAU stipulates that a “live surgery director” should be appointed for each event. This senior clinician should be responsible for coordinating the entire process and selecting the guest surgeon. Perhaps the EAU policy should also expli citly state that the guest surgeon must be VOLUME 11 | MAY 2014
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS highly experienced in the chosen procedure and have a proven track record of teach ing and operating under pressure. Future versions of the policy might also include a pre-LSE audit of the guest surgeon’s case numbers and results. A more important shortfall of the EAU policy is that it does not emphasize surgi cal rehearsal. A full rehearsal prior to the LSE could lead to improved performance on the day.10 In particular, the guest surgeon and host team should be introduced, roles should be clarified, the timing of anaesthesia, surgical start, and uplink must be agreed, positioning and specific requirements of the case should be checked, and all clinical concerns should be discussed before the day. The moderators could also prepare the guest surgeon for likely questions, and parameters for ceasing broadcast should be set (for example, running over time or excessive blood loss).4 Finally, the EAU policy prescribes rigor ous postoperative care and mandates the reporting of complications through the EAU web-based Live Surgery Registry (set up 2 years ago). This thorough approach should reassure critics that LSEs are being conducted in an ethical and transparent manner, and that complication rates are being audited carefully by this professional body.
MAY 2014 | VOLUME 11
In summary, the EAU policy statement on live surgery is an admirable effort to safe guard patients while preserving the concept of live surgery for the future. The EAU will regularly revisit and refine the policy statement, and there are areas of potential improvement in relation to surgical rehearsal and the provision of selection guidelines for guest surgeons. Urology, Level 1, Southwark Wing (M.B.), MRC Centre for Transplantation, NIHR Biomedical Research Centre, Kings College (P.D.), Guys Hospital, Great Maze Pond Road, London SE1 9RT, UK. Correspondence to: P.D. [email protected] Acknowledgements P.D. acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. He also acknowledges the support of the MRC Centre for Transplantation and grants from the Guy’s and St Thomas’ Charity, EU‑FP7, The Urology Foundation, The School of Surgery, Olympus, Heathside Trust and The Vattikuti Foundation. M.B. holds a Robotic Fellowship at Guy’s, which is supported by educational grant funding from Intuitive Surgical and The London Deanery. Competing interests The authors declare no competing interests.
1.
Toouli, J. What is the role of “live surgical demonstrations” at conferences? HPB (Oxford) 8, 163–164 (2006). 2. Duty, B., Okhunov, Z., Friedlander, J., Okeke, Z. & Smith, A. Live surgical demonstrations: an old, but increasingly controversial practice. Urology 79, 1185.e7–1185.e11 (2012). 3. Sugarman, J., Taylor, H., Jaff, M. R. & Sullivan, T. M. Live case demonstrations: attitudes and ethical implications for practice. Ann. Vasc. Surg. 25, 867–872 (2011). 4. Challacombe, B., Weston, R., Coughlin, G., Murphy, D. & Dasgupta, P. Live surgical demonstrations in urology: valuable educational tool or putting patients at risk? BJU Int. 106, 1571–1574 (2010). 5. Artibani, W. et al. EAU Policy on Live Surgery Events. Eur. Urol. http://dx.doi.org/10.1016/ j.eururo.2014.01.028. 6. Kallmes, D. F. et al. Live case demonstrations: patient safety, ethics, consent, and conflicts. Lancet 377, 1539–1541 (2011). 7. Devière, J. et al. Recommendations of the ESGE Workshop on Ethical-Legal Issues Concerning Live Demonstrations in Digestive Endoscopy. First European Symposium on Ethics in Gastroenterology and Digestive Endoscopy, Kos, Greece, June 2003. Endoscopy 35, 765–767 (2003). 8. Guillonneau, B. Live surgical demonstration: is it worthwhile? Nat. Clin. Pract. Urol. 4, 59 (2007). 9. Schmit, A. et al. Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations. Endoscopy 37, 695–699 (2005). 10. Hamilton, L. et al. Seminar Report. The Royal College of Surgeons [online], http:// www.rcseng.ac.uk/policy/policy-seminars/ live-surgery/seminar-report (2014).
www.nature.com/nrurol © 2014 Macmillan Publishers Limited. All rights reserved
