Observation has long been a key component of the dissemination and teaching of surgical techniques. Where this once involved watching from a viewing gallery, most contemporary microsurgical operating theaters incorporate video-recording facilities and television monitors. Operating room staff and observers can now easily follow the progress of an operation. Advances in digital video editing have allowed recorded video footage of surgery to be used routinely in surgical teaching. With the development of video-conferencing facilities, direct transmission of surgery from an operating suite into a conference hall, usually with 2-way communication between the operating surgeon and the audience, has also become common practice in ophthalmology. Such demonstrations are commonly referred to as live surgery. Live surgery demonstrations and participating surgeons are often sponsored by industry.
Proponents of live surgery cite the interactive value of modern presentations. Delegates and panelists at conference presentations are able to put questions to the surgeon as he or she operates, and the surgeon will normally provide a commentary highlighting key elements of technique. Others observe that a similar interaction would be possible alongside the presentation of recorded video footage. There are also concerns that live surgery may entail unnecessary risks for the patient.1,2 Continuity of care may be disrupted2 as cases selected in advance for a visiting surgeon to operate on live are normally only reviewed by the surgeon once before and once after the operation. Local support staff may be inadequately trained in the operation of new equipment or other elements of the technique being demonstrated. Surgical performance may also be affected by the additional stress associated with operating in front of a large audience of other surgeons.
We surveyed United Kingdom consultant ophthalmologists with the aim of determining whether the prevailing view is that live surgery is an essential adjunct to teaching with edited video footage or that any benefits are outweighed by the attendant risks.
MATERIALS AND METHODS
The questionnaire was approved by the honorary secretary of the Royal College of Ophthalmologists, after which names and addresses of all the consultant ophthalmologists in the UK were provided. Consultant ophthalmologists have completed their training and obtained a substantive National Health Service hospital appointment. This questionnaire and a stamped addressed envelope in which to return the completed survey were sent to all consultants. The accompanying covering letter stated that live surgery was defined as “surgery performed in real time and relayed to an audience, usually at a conference.”
The questionnaire was developed after discussion with an informal focus group of UK and overseas ophthalmologists. Opinion was surveyed in 10 areas relating to live surgery, with forced-choice (“yes” or “no”) sub-items relating to each area (Table 1). Responses were entered into an Excel spreadsheet (Microsoft). There was no neutral option (“don't know”). Failure to record a “yes” or “no” answer was recorded as “not answered.” Proportions recording “yes” or “no” answers for each item were calculated by dividing the number of “yes” or “no” responses by the total number of respondents, including those failing to record an answer.
Four additional questions allowed free-text responses. Respondents were asked to provide details of any perceived benefits (item 4e) or disadvantages (item 5e) of live surgery beyond those covered in the questionnaire. Question 8b asked what were the benefits, if any, of live surgery that could not be achieved by watching a video. Question 11 asked for further comments regarding live surgery.
Responses were received from 63% of UK consultant ophthalmologists (536/856). Results for forced-choice items are summarized in Table 1. Suggested benefits of live surgery in free-text answers included interactivity and the opportunity to observe the reality of other people's surgery. Unprompted disadvantages cited included the inefficient and time-consuming nature of viewing live surgery in comparison with edited video footage and the possibility that distractions and added pressures involved may compromise surgical performance.
The possible benefits of live surgery that could not be provided using recorded video cited by respondents included the interaction between the surgeon and the audience (34 of 83 comments), real-time unedited surgery (30), how to deal with the unexpected/complications (11), head placement/positioning (3), reassurance that even experienced surgeons have complications (2), the ability to assess the duration of surgery more accurately (2), and that live surgery is more exciting (1).
Two hundred fourteen respondents provided a response to the final open question requesting further comments. In 48 responses, those performing live surgery were criticized, with respondents variously describing them as focused on self-promotion or exhibitionism or otherwise dubiously motivated. There were 35 comments about video being a better teaching method, particularly if the surgeon was available to communicate with the audience. Twenty respondents stated that they believed that live surgery was unethical, with another 12 stating that it should be banned. Some said they thought that voyeurism was one reason people watched live surgery (3 respondents), and it was described as a “blood sport” or like watching “cock fighting,” “bullfighting,” or a “Formula 1 car crash” (6 respondents). Some commented that the stress on the surgeon was considerable (5 respondents), and some said the complication rate was too high (6 respondents). Concerns were also recorded regarding litigation, the promotion of sponsors' messages, and the legality of visiting non–European Union physicians performing surgery in the UK (2 respondents each).
Positive or mitigating responses to the same open question included the view that teaching surgery is inevitably associated with risk (5 respondents), that live surgery may have particular efficacy in teaching (3 respondents), and that it provides the opportunity to see some of the best surgeons operating (2 respondents). Some commented that live surgery should continue to be performed but with strict guidelines (4 respondents), with more fully informed consent (14 respondents), or in familiar operating rooms only (10 respondents). Others said they believed that if the surgeon was experienced in live surgery and confident, the risks were not greater (4 respondents). Others said that live surgery was an appropriate teaching method for charitable work in developing countries, such as through Orbis (13 respondents) (http://www.orbis.org.uk. Accessed March 16, 2008).
This survey indicates clearly that although legitimate arguments in favor of live surgery remain, the majority of UK consultant ophthalmologists harbor significant concerns about its safety and teaching value. It is not known how the complication rate of live surgery compares with the background rate. The European Society for Cataract & Refractive Surgeons (ESCRS) had advised that it is currently auditing the complication rate in live surgery performed at ESCRS-sponsored events. Whatever the actual complication rate, the survey summarized in this paper suggests that the majority of consultants in the UK (68% of questionnaire respondents) perceive the complication rate of live surgery to be higher than the background rate.
Other surgical specialties have attempted to assess the outcomes of live demonstrations. In a study assessing the participants' views on the success of coronary angioplasty performed at 12 live surgical demonstration courses, it appeared that the results were generally inferior to those reported in journals.3 A study comparing patients having endoscopic retrograde cholangiopancreatography (ERCP) during live demonstrations with matched patients treated in an ERCP unit showed no significant difference in the success or complication rates; however, the live-demonstration patients were much more likely to have general anesthesia.4
In the context of a conference in particular, live surgery often involves a surgeon performing an operation in an unfamiliar operating room after a relatively brief preoperative consultation. Stress and jet lag may impair judgment during the operation, and the operating surgeon may be unavailable to treat postoperative complications. Unfamiliar surroundings were cited as a disadvantage of live surgery by 91% of respondents in our survey, and 92% indicated that live surgery imposed additional stress. Eighty-three percent of respondents said they believed that having an operation performed as part of a live-surgery event is not in the patient's best interest. Inadequate consent was another stated disadvantage of live surgery, cited by 46% of respondents.
Direct transmission of surgery has been thought to be a good educational and training tool. In this survey, however, only 55% of respondents agreed that teaching surgical techniques was an advantage of live surgery. Most surgeons now have access to video recording and editing facilities. Asked whether there are teaching benefits from watching live surgery that cannot be achieved by watching a video, only 26% of respondents agreed; the main benefit cited by the minority of respondents agreeing was the possibility for interaction with the surgeon. The unedited nature of live surgery was also proposed as a teaching benefit. Against these perceived advantages of live surgery, other respondents commented that videos can be presented unedited and with an interactive commentary. Recorded videos can also be paused and rerun to emphasize points that could be missed in a live presentation.
This study could be criticized for the way the questions were asked, with 2 respondents commenting that they thought the authors had an obvious preexisting bias against live surgery. Every attempt was made to frame the questions nondirectively and to provide free text space for opinions for and against live surgery. A combination of open- and closed-format questions was used. This combination has been suggested as the best format for questionnaires assessing opinions.5 The questionnaire items were derived from opinions canvassed informally at recent international conferences of ophthalmologists, including both advocates and opponents of live surgery. The questionnaire was assessed by medical professionals and lay representatives to ensure the questions were not biased.
Other criticisms could include the fact that not all consultant ophthalmologists returned the questionnaire. However, the response rate of 63% was high for surveys of similar design. A review of the literature looking at the response rates of other postal surveys of UK consultant ophthalmologists showed that usually less than 50% of consultant ophthalmologists responded.6–11 In addition, some respondents did not answer all questions and a neutral or “don't know” option was not included in the forced-choice list. However, the respondents who left a particular question unanswered were taken into account when calculating the percentages answering “yes” or “no.”
Nearly two thirds of the UK consultants who replied thought that live surgery should no longer be performed, with only a quarter stating that it should. It is not clear whether the commercial sponsors of live surgery are aware that there may be such significant negative feeling toward live-surgery events. It might also be argued that patients should be informed during their consent that a high proportion (83%) of consultants believe that having an operation performed as part of a live-surgery event is not in the patient's best interest.
Recently, a statement endorsed by the 2007 Council of the Royal College of Ophthalmologists regarding live surgery demonstrations appeared on the council's web site (http://www.rcophth.ac.uk/finance-membership/members/live-surgical-demonstrations. Accessed March 16, 2008). This statement acknowledges concerns about patient consent, additional surgical pressure, equivalence of training, and medical indemnity for the visiting surgeon. Other specialties are also beginning to act on live surgery. The European Society of Gastrointestinal Endoscopy has derived guidelines for live endoscopy demontrations.12 These include the formation of a committee to oversee the ethics, organization, and moderation of live-surgery events.
These guidelines acknowledge the hazards of current live-surgery demonstrations but presuppose that live surgery will continue to be supported. Opinions from UK ophthalmology consultants expressed here suggest that many surgeons now believe that edited footage is a more efficient and safer teaching tool. When presented alongside representative outcome data and inclusive of complications, edited footage should be a sound vehicle for illustrating the potential and limitations of any new technique. This survey sets the agenda for continued audit of live-surgery results and an extension of the debate to other specialties.
1. Millat B, Fingerhut A, Cuschieri A., 2006. Live surgery and video presentations: seeing is believing…but no more: a plea for structured rigor and ethical considerations [editorial], Surg Endosc, 20, 845-847.
2. Guillonneau B., 2007. Live surgical demonstration: is it worthwhile? [editorial], Nat Clin Pract Urol, 4 (2), 59.
3. Chatelain P, Meier B, de la Serna F, Moles V, Pande AK, Verine V, Urban P. Success with coronary angioplasty as seen at demonstrations of procedure. Lancet. 1992;340:1202-1205.
4. Schmit A, Lazaraki G, Hittelet A, Cremer M, Le Moine O, Devière J. Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations. Endoscopy. 2005;37:695-699.
5. Leung W-C. How to design a questionnaire. Student BMJ. 2001;9:187-191.
6. Schieman M, Cooper J, Mitchell GL, De Land P, Cotter S, Borsting E, London R, Rouse M. A survey of treatment modalities for convergence insufficiency. Optom Vis Sci. 2002;79:151-157.
7. Choudhuri I, Sarvananthan N, Gottlob I. Survey of management of acquired nystagmus in the United Kingdom. Eye. 2007;21:1194-1197.
8. Ng J, Kashani S, Qureshi K, Ferguson V., 2007. Intraocular pressure measurement and Goldmann calibration. An eye opening review of practice in United Kingdom [letter], Eye, 21, 851-853.
9. Kashani S, De Silva DJ, Aslam S, Maini R., 2007. A survey of excimer laser use among consultant ophthalmologists in United Kingdom [letter], Eye, 21, 279-281.
10. Gordon-Bennett PSC, Ioannidis AS, Papageorgiou K, Andreou PS. A survey of investigations used for the management of glaucoma in hospital service in the United Kingdom. Eye 2008. E-pub ahead of print.
11. Little BC, Alyward GW. The medical management of traumatic hyphaema: a survey of opinion amongst ophthalmologists in the UK. J R Soc Med. 86. 2003. 458-459. Available at: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1294050&blobtype=pdf
. Accessed March 11, 2008.
12. Kruse A, Beilenhoff U, Axon AT. ESGE/ESGENA guideline for live demonstration courses. Endoscopy. 2003;35:781-784.