Journal of Visceral Surgery (2019) 156, 279—280

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EDITORIAL

Should we ban Live Surgery?

If you consider that Live Surgery designates a situation where surgery is performed in the
presence of individuals not directly involved in the patient’s care, there is nothing new
under the sun. So why all the hullabaloo about Live Surgery?
Actually, although Live Surgery has been around since time immemorial, it recently
came into the limelight with the advent of new technologies and progress in medical
ethics; patients and surgeons have come to question its legitimacy. A little history might
be helpful.
Before the 20th century, the surgeon operating in his theater was the performance to
see. There really wasn’t any ethical problem. Ample examples of the vulgum pecus getting
the shivers watching a barber surgeon wield the lancet, saw and trepan on a suffering
patient can be found in Romanesque novels. For instance, the club-foot episode in Gustave
Flaubert’s Madame Bovary: thrill-seekers were captivated when her husband, a modest
health officer, blotched an Achilles tendon resection and ended up carving an above-the-
knee amputation [1].
But from the beginning of the 20th century, aseptic conditions became the golden rule
for surgical procedures, making the operating theater off limits for the general public.
The audience was restricted to university hospital residents in training or senior surgeons
visiting a colleague in another city or country to learn a new technique. Initially the visitors
were physically present in the room, but later glass-domed amphitheaters were designed
so the audience could view the operation from above without any direct contact with the
operative table.
By the end of the 20th century and the early 21st, all was to change. What was new was
the concomitant development of several advanced technologies — live video transmissions,
e-congresses, social networks — and consequently the modern version of Live Surgery. For
many, the advantages were patent, while for others more inclined to focus on patient’s
rights than personal ego, so were the disadvantages. Hence, Live Surgery sessions became
the leading attractions of surgery conventions, some even proposing simultaneous oper-
ations so the organizers could switch viewers from one theater to another to highlight a
more instructive procedure (or skillful operator), or inversely to skip over an intraoperative
complication that might spoil the party. There’s been a plethora of scientific articles and
letters-to-the-editor in the medical literature on the topic recently analyzed in detail in
a book published by Harmattan [2]. One series of articles in European Urology shows how
heated the debate has become in the urology community. After the European Association
of Urology (EAU) invited 24 surgeons to write good practice guidelines for Live Surgeries
[3,4], they received a highly critical letter-to-the-editor from an author proclaiming their
hypocrisy [5]. The EAU replied to this attack by the affirmation that there is no proof of the
pedagogic value of Live Surgery, no more for live transmissions than for delayed retransmis-
sions [6]. Another author reacted in another letter-to-the-editor, stating that e-congress
webcasts of Live Surgeries are better than inviting surgeons/travelers to work in extreme
conditions [7,8]. A third author suggested that given the high risk of complications, it would
be in patients’ best interest if we banned Live Surgeries altogether [9].

https://doi.org/10.1016/j.jviscsurg.2019.06.005
1878-7886/© 2019 Elsevier Masson SAS. All rights reserved.
280
The purpose of this editorial designed as a warning signal,
is to draw practitioner’s attention to the risks and excesses
of Live Surgeries.
Surgeons who operate under these conditions are
exposed to undeniable psychological stress related to the
close scrutiny of an expert audience ready to criticize and
the obligation to answer difficult questions, sometimes in a
foreign language, while continuing the operation. In certain
cases, the surgeon is guilty of illegal practice of medicine
since the normal prerequisites — diploma recognized by the
inviting country, registration with the local Medical Board,
contract or convention signed with the healthcare institu-
tion — and of course a specific insurance coverage, have not
been validated with supportive documents.
The patient has not always received adequate and hon-
est information before Live Surgery. Many times, the patient
doesn’t even know the operation will be filmed, or is
unaware the operating surgeon is not the surgeon who con-
ducted the preoperative examination. Did anyone mention
that the indication could be changed at the last minute to
satisfy the sacrosanct program announced as the highlight
of the Live Surgery session? Does the patient know that the
operator may have jet-lag, or will not be responsible for any
post-operative complications? Is the patient aware that his
confidential medical file has been disclosed without his con-
sent to a large number of individuals who are not involved
in his care, in overt violation of medical secrecy and the
Hippocratic Oath?
Many learned societies have pudically proposed (unen-
forceable) good practice guidelines to regulate the
organization of Live Surgeries. Do we need a more restrictive
framework? Will punitive measures be needed to guaran-
tee compliance with yet-to-be-written mandatory rules? Or,
since there is no proof of any pedagogic value and since
we know that pre-recorded videos, when well prepared
and properly presented, can provide as much, if not more,
pertinent information to enrich the knowledge and skill of
viewers, perhaps we should quite simply ban Live Surgeries.
No one can deny the great contributions these new tech-
nologies have made to modern education [10], yet it remains
obvious that the art of surgery (etymologically manual skill)
basically has to be learned by apprenticeship. Watching
a mentor operate remains an essential part of training
because no normative industrial process will ever replace
the human relationship which lies at the heart of our work!
We must not sacrifice medical ethics on the altar of surgi-
cal showbiz Live Surgery has become today! Surgeons have
to face up to the issue of Live Surgery and make the right
decisions, now, before a scandal breaks out in the medias
heaping shame on our profession.
Editorial
Disclosure of interest
Philippe Liverneaux has conflicts of interest with Newclip
Technics, Argomedical.
References
[1] Flaubert G. Madame Bovary. Folio classique.
[2] Liverneaux P. Live Surgery. Alerte sur une pratique médicale
dangereuse. Paris: L’Harmattan; 2018.
[3] www.uroweb.org.
[4] Artibani W, Ficarra V, Challacombe BJ, et al. EAU pol-
icy on Live Surgery events. Eur Urol 2014;66(1):87—97,
http://dx.doi.org/10.1016/j.eururo.2014.01.028 [Epub 2014
Jan 30. Review. PMID: 24560818].
[5] Murphy DG. Let the games begin (with EAU approval).
Eur Urol 2014;66(1):98—100, http://dx.doi.org/10.1016/
j.eururo.2014.02.008 [Epub 2014 Feb 15. PubMed PMID:
24560817].
[6] Artibani W, Parsons KF. Reply from Authors re: Declan
G. Murphy. Let the games begin (with EAU approval).
Eur Urol 2014;66(1):98—100, http://dx.doi.org/10.1016/j.
eururo.2014.02.049 [No games: Live Surgery events endorsed
by EAU under strict regulations. Eur Urol. 2014 Jul;66(1):100-1.
doi: 10.1016/j.eururo.2014.02.049. Epub 2014 Mar 4. PubMed
PMID: 24642262].
[7] Re: Walter Artibani, Vincenzo Ficarra, Ben J, Challa-
combe, et al. EAU policy on Live Surgery events. Eur Urol
2014;66:87—97 [Collins JW, Akre O, Wiklund PN. Eur Urol. 2014
Dec;66(6):e121-2. doi: 10.1016/j.eururo.2014.07.009. Epub
2014 Jul 24. PMID: 25065527].
[8] Collins J, Hosseini A, Challacombe B, et al. Live streaming
of robotic surgery from leading educational centres enables a
global approach to surgical teaching. J Urol 2016;195(4):116,
http://dx.doi.org/10.1016/j.juro.2016.02.2383 [Issn Print:
0022-5347].
[9] Re: Walter Artibani, Vincenzo Ficarra, Ben J, Challa-
combe, et al. EAU policy on Live Surgery events. Eur Urol
2014;66:87—97, http://dx.doi.org/10.1016/j.eururo.2014
.08.015 [Noordzij A, van Dijk G. Eur Urol. 2014 Dec;66(6):e119.
Epub 2014 Aug 20. PMID: 25151016.].
[10] Brunaud L. Will watching videos make us better surgeons? J
Visc Surg 2013;150:295—6.
P. Liverneaux
Department of hand surgery, SOS main, university
hospital of Strasbourg, FMTS, university of
Strasbourg, Icube CNRS 7357, 1, avenue Molière,
67000 Strasbourg, France
E-mail address:
Philippe.liverneaux@chru-strasbourg.fr
Available online 8 July 2019