Live surgical workshops: Balancing patient care and professional development

Benefits of LSWs for patients and surgeons

LSWs offer important benefits to both the surgical community and patients (Table 2). For surgeons, LSW is an excellent training tool that allows real-time observation of surgical procedures by expert surgeons. Apart from honing important surgical skills, such live events allow participants to learn about mundane yet critical steps in surgical planning and execution, such as theatre management, patient positioning, surgical instrument setup, layout of instrument stacks, and team communication. A LSW also provides an unparalleled opportunity for attendees to engage directly with expert surgeons, gaining a deeper understanding of the reasons behind the implementation of specific protocols.¹⁵ Several studies have emphasized the benefits derived from such LSWs as participants have expressed their intent to attend fewer workshops if LSWs were not part of the programme.¹⁶ They also consider LSWs preferable to other forms of surgical training such as edited video broadcasting in terms of improvement of surgical skills, on-the-spot decision-making and higher probability of transfer of acquired skills into clinical practice.^5,17,18 However, concerns have been raised by the community regarding the perceived benefits for the audience and anticipated issues related to ethics and safety.

From the patient’s standpoint, LSWs are immensely beneficial as they are performed by expert surgeons with extensive experience in the field, which may not be available locally.⁵ The surgeries are performed according to best practices and evidence-based guidelines, with meticulous planning and attention to detail. LSWs also help increase the transparency of surgical procedures and enhance patients’ understanding. The constant feedback, continuous refinement, and advancement of surgical techniques are the objectives of such LSWs, which translate into better patient outcomes in the future. The continuous feedback, improvisation and refinement in surgical techniques that occur during LSWs ultimately translate into better patient outcomes in the future.

Patient safety and efficacy of surgeries conducted during LSW

The data regarding the safety and success of surgical procedures performed as live events in various fields, such as urology, gynaecology, cardiology, gastroenterology, and bariatric surgery, are provided in Table 2. All the studies are retrospective with no comparison arm or a historical cohort serving as a comparison. In addition, the studies are heterogeneous in terms of setting (international or national workshops), place of surgery (home or foreign institution), surgical approach (open versus minimally invasive), surgical discipline, diagnosis, surgical complexity and surgeon proficiency. The majority of studies show comparable results in terms of complication rates, surgical events, and long-term outcomes for patients operated in LSWs compared to those operated in a clinical setting.^19–32 Only one study by Ruiz et al. showed a slightly higher morbidity and reoperation rates in patients undergoing bariatric procedures in the LSW arm compared to the overall series of patients operated on in their institute. The authors acknowledged the presence of differences in patient characteristics of the LSW arm and the overall series, but they did not conduct statistical tests to quantify these differences, thereby raising concerns about the comparability of the arms. Notably, 85% of their cases were performed by invited surgeons from outside the home institution, and 35.2% of patients underwent revision surgery following a failed primary operation, indicating higher surgical complexity.³³ Similarly, concerns regarding under-reporting of adverse events, variations in surgical efficiency and outcomes when operating at home versus ‘foreign’ institutes have been raised by several authors.^18,34,35 The majority highlighted that the success of any treatment relies on the cohesive effort of the entire team working together, and this cohesion is best achieved within the home institution.

Experiences of operating surgeons and attendees during LSWs

Several surveys have evaluated experience of surgeons and attendees regarding multiple avenues such as the educational benefit of LSWs compared to other training methods, stress on surgeons to showcase their proficiency, distractions during surgery (comments from moderator or questions from participants), physical factors (jet lag), unfamiliarity of surgical team, operating theatre and/or instruments. The summary of studies highlighting these factors is presented in Table 3. Nearly all attendees unequivocally endorsed the educational advantages of LSWs.^{5,6,17,35–37} Most surveys comparing the perceived learning benefits and preferences of attendees consistently favoured LSWs over cadaveric surgery and edited/unedited videos.^5,17,38 However, few studies supported pre-recorded videos over LSWs.^6,16,34,39 The option of LSB, where surgeons operate in familiar surroundings alongside trusted associates, has been deemed equally effective, offering the added benefit of reducing stress and anxiety levels amongst surgeons. The perception of the surgical community regarding LSB versus LSW has been conflicting. One school of thought supports LSW; that the human body is a universe unto itself, teeming with boundless potential. Surgeons, whether in live procedures or not, inevitably encounter unforeseen challenges. The essence of learning in LSW lies in participants gaining insights from field masters on navigating these unexpected intricacies and surgical challenges. During an LSW, participants are immersed in and actively engage with the surgical experience from both the patient’s and the operating surgeon’s perspectives. Simultaneously, they maintain an objective stance, observing the procedure from an independent third perspective. The distinctive experience of an LSW cultivates a deep learning process amongst participants.

Another perspective supports using LSBs from the surgeon’s own environment, ensuring patient confidentiality. Unedited, LSBs offer the same educational value as LSWs in foreign settings, reducing surgeon stress and addressing ethical concerns. During unexpected incidents, a team member or moderator can assist in decision-making, preventing additional stress for the operating surgeon. Hence, LSBs are perceived as a means to combat the challenges of disseminating complex surgical skills while maintaining the continuity of care. Some surgeons advocate for the use of practical scenarios or videos to sharpen on-the-spot decision-making skills with equal utility. Such pre-recorded videos can also be used to stimulate conversations surrounding personal experiences in managing difficult cases and receiving expert opinions on alternative or better management and/or surgical techniques. However, watching pre-recorded videos often results in surface-level learning, where participants tend to adopt a narrow viewpoint and aim for rote memorization rather than true comprehension, as discussed by Marton and Säljö in their concepts of deep and surface learning.⁴⁰ Overall, no well-designed quantitative studies have been done to ascertain the superiority of any of these modalities over others.

Most surgeons expressed concerns about factors such as distracting discussions, jet lag and unfamiliar surroundings.³⁵ It is noteworthy that the potential harms of LSWs were perceived to be greater by operating surgeons compared to the attendees who benefited more from such live surgical events.⁴⁰ Hence, there is a need to address the potential concerns affecting surgeon’s experience during the conduct of LSWs.

Ethical concerns related to surgeries performed in LSWs

Opinions of performing surgeons and attendees of LSWs regarding concerns on patient confidentiality, consenting, ethical issues of LSWs, selection of difficult cases and/or surgical techniques for purposes of showcasing surgeon’s proficiency have also been analysed.³⁵ Other potential concerns include infection control issues due to the presence of non-medical professionals in a sterile OR (camera man and technical support), impact of potential waiting times for workshop on patient outcomes, limited availability of surgical time, interruption of surgery to perform the subsequent case, ethics of operating on patients with little interaction preoperatively and lack of postoperative care.

Efforts such as delaying transmission until the patient is fully draped, selecting cases after multidisciplinary team discussions with shared reports and images, limiting the number of non-OR staff present during LSWs and conducting patient interactions before the day of surgery while informing them about the surgeon’s unavailability for postoperative care have been implemented. However, there has been no systematic analysis of these practices. In response to the concerns mentioned above, many studies have adapted good practices such as obtaining consent specifically tailored to the live relay of surgery by the invited surgeon, citing the impact of stressors on surgical performance during LSB, involving a patient advocate in conducting LSWs and assigning responsibility to surgical teams for preoperative and postoperative care of the patient and establishing thresholds for stopping transmission to reduce distractions.^19,26 There should be sufficient transparency in the process. It is essential to emphasize that no economic incentives should be offered to patients in exchange for their consent. However, there is no universal mandate for the format of ethical consent for this issue that is legally valid.

Common themes identified in position papers/guidelines to overcome perceived challenges in conducting LSWs from various surgical societies

Various surgical societies have endorsed several common themes to mitigate the untoward concerns in the conduct of LSWs.^9–11 This period starts from the preoperative phase until the patient is discharged from care. Surgeons are encouraged to perform surgical procedures at their respective home institutions to avoid undue anxiety and stress associated with travel, and to have the comfort of operating with familiar teams. These surgeries are then streamed on a digital platform and transmitted to a conference centre, leveraging technological advancements. This approach preserves the fundamental essence and educational value of a live surgery event, while prioritizing patient safety above all else. Unlike traditional live surgery broadcasts, where case selection, preoperative assessment and postoperative care may not be directly overseen by the operating surgeon, in this format, these aspects are managed by the operating surgeon. By having moderators communicate with non-operating surgeons and assistants in the OR, potential distractions to the operating surgeon are mitigated, thereby allowing for greater focus on the surgery itself. The surgeon may be interviewed at the conclusion of the procedure to share their experience and answer attendee questions.

Consents should be designed specifically for LSW broadcasting, in addition to those for the specific surgical procedure itself, with information on details of the broadcast, the potential number of participants, the impact of such transmission on patient outcomes, and the educational intent of the relay. The patient should also be informed that the visiting surgeon will lead the surgery under the supervision of the local team, who will subsequently take over further management. The patient has the right to refuse participation after being informed of the potential benefits and risks associated with LSWs.¹⁰ Coercing patients into consenting to LSWs with the promise of expedited treatment, financial benefits, or other perks should be avoided. To avoid any disadvantage if they decline, an alternative surgical slot should be provided. Obtaining approval from the Institutional Ethics Board is necessary to ensure strict adherence to good clinical practice and to prevent patient exploitation. A patient advocate must be involved in organizing the LSW to ensure that the procedure is in the patient’s best interests. Patient confidentiality is of utmost importance and should be maintained by using de-identified language by OR staff and by conducting regular training sessions. Patient dignity should be maintained by starting transmission only after the patient is appropriately draped. A protocol should be established for training non-medical staff present in the OR on infection control measures.

To conclude, LSWs have immense educational potential and a unique benefit for patients who are otherwise unable to access expert medical care. The concerns raised for such LSWs appear to be more substantiated in qualitative studies exploring the surgeon and attendee’s perspectives, rather than objective quantitative studies examining patient safety and outcomes. Overall, while onsite operative workshops have their advantages, these can be replicated in one’s native environment, ensuring continuity of care. In addition, it is a fact that several adverse incidents were under-reported, as there is no defined mandate for reporting adverse events at LSWs, nor a system in place to ensure safety procedures and ethical standards that are legally enforceable.