Ophthalmologists weigh pros, cons of live surgery events, potential alternatives
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For a long time, live surgery sessions have been an important part and distinctive feature of the scientific program of many major ophthalmology meetings worldwide.
They are generally well attended, with a high degree of appreciation by the audience, and offer to both the participants and the attendees a unique opportunity to enhance their surgical skills by learning new techniques and interacting with internationally renowned colleagues.
However, there are also complex issues involved in organizing and participating in live surgery events, and safety and ethical concerns have led some of the societies to take a step back, set limitations, issue guidelines or even look for alternatives.
“We all learn surgery by watching or doing live surgery. Almost every week I have somebody in the OR with me to observe or learn a technique,” Brandon D. Ayres, MD, said. “But when you scale live surgery up to large events, and the surgeons are out of their comfort zone, you do begin to have some ethical issues: Should you be doing that? Is it really in the patient’s best interest? And are you absolutely comfortable being there?”
Seeing it as it happens
Healio/OSN Section Editor Uday Devgan, MD, has participated in many live surgery events at major meetings in the U.S. and several countries abroad. He enjoys being there as a surgeon, and as an audience member, he sees the sessions as a uniquely engaging learning experience.
“It’s a neat way of really learning and seeing live what we do, in the same way that it’s fun to watch live sports. And a big part of this is that you can see everything behind the scenes. You see it as it happens,” he said.
“Most people really like live surgery because it’s live, it’s raw, and you get to see what the real experience is, with no filters, no editing,” Healio | OSN Glaucoma Board Member Savak “Sev” Teymoorian, MD, MBA, said.
Nowadays, there are plenty of surgical videos available online or made available by companies, “but until you actually get to see all the little steps and subtle nuances of the procedure that normally are not shared, you don’t get a full grasp of it,” he said.
In addition, surgeons have the opportunity to learn from top-tier specialists, and patients with complex problems have the opportunity to be matched with experienced surgeons, usually with no charge for the operation.
Complications might occur, as they do in any surgical setting, and increase the audience’s attention and engagement.
“If you watch an F1 car race, you like to see the action, even an accident as long as no one gets hurt. So, people in the audience may even want to see a complication,” Devgan said.
However, experienced surgeons know how to keep calm and fix a complication.
“Recently I was in the panel of a live surgery session in Brazil, and during a cataract procedure, there was an Argentinian flag sign. The surgeon did a marvelous job of rescuing that case and giving the patient a fantastic outcome,” Devgan said.
In the U.S., many meetings have replaced live surgery sessions with the projection of prerecorded 3D videos, which everyone in the room can watch using polarized glasses. According to Ayres, they offer the opportunity to feel even more involved in the case and to manage time better.
“It is more like being at the microscope than just watching surgery on a screen. It also allows for more cases to be presented because you already know how long each case is going to be, and you can edit the video to make it a little bit shorter, so that you can fit in more discussion and more cases during the allotted time. With live surgery, if you have four or five cases scheduled to be shown and there is a complication or malfunction of equipment, all of a sudden you are off schedule,” he said.
Devgan is more skeptical about the prerecorded video alternative.
“It’s not the same, really. And to be frank, even a 3D video is not as good as a 2D live surgery. In your home, how many 3D TV sets do you have? None. It’s not really that much more learning, and there is the nuisance of having to wear polarized glasses,” he said.
While still popular and highly appreciated abroad, large live surgery events do not occur as frequently in the U.S.
“I travel a lot. I have been involved in meetings in 12 countries this year, and I can say that in most meetings they like to have live surgery. But here it is hard to find surgeons who want to do live surgery events because they don’t want to be put on the spot,” Devgan said.
Challenges for the surgeon
Live surgery is indeed challenging for the surgeon because it is much more than just doing the actual surgery, Teymoorian said.
“You have to be able to multitask. Not only are you doing the actual surgery, you are also trying to keep the patient calm while you are not talking to them but to an audience, trying to speak clearly and explain what you’re doing. And you only have one chance. There’s no going back and editing,” he said.
In addition, there is the challenge of operating in an unfamiliar setting.
“You are not in your own operating room. The staff, the equipment, the light, everything is different from what you are used to, and you don’t really know the patients well,” Devgan said.
Every moment and every detail of surgery are filmed by multiple cameras from different angles.
“There’s the recording from your microscope camera, but in addition, there is a close-up camera, there is a camera on your hands, sometimes there is a camera on your phaco foot pedal, and you may have to modify the way you hold the instruments slightly. In my left hand, I usually hold the chopper like a pencil, but when I’m doing live surgery, that blocks the view of a camera, so I have to hold the instrument bending my hand instead,” he said.
Even more challenging is that the surgeon has to respond to two inputs from two earpieces at the same time.
“One earpiece is the moderator, who is an ophthalmologist in the audience, talking to me and asking me questions about what I am doing. The other one is the director telling me to set up the microscope, move my left hand and so on,” Devgan said. “And, of course, you are judged by peers because everyone who is watching you does the same surgery. So, it’s certainly a high-pressure, high-stakes situation.”
When surgeons perform live surgery abroad, the language barrier is something else to overcome.
“When I was doing live surgery at Lucio Buratto’s meeting in Italy many years ago, I had to remember how to say, ‘Signora, per favore guardi la luce!’ [Madam, please look at the light!],” Devgan said.
Antidotes to stress
Preparation reduces stress, and Teymoorian suggested that surgeons, whenever possible, should try to get some experience beforehand with the room and the equipment and have a discussion with the patients.
“Tell them things like, ‘I want to make sure you’re comfortable even though we’re doing a live surgery. If at any point you are uncomfortable, please let me know.’ Also tell them there will be times when you are not going to be speaking with them but with colleagues on a camera and that you will clearly address them if there is anything in particular you need for them to do,” he said.
“My best antidote to stress is getting a good night’s sleep the night before and no alcohol and no coffee because I want to be rested and focused,” Devgan said.
He also emphasized the importance of getting to know the patients beforehand and learning the words to use when interacting with them if they speak a different language. Talking with the moderator ahead of time is also important.
“In my case, I want to make sure they stay on the point, asking me questions only about what I am doing. If I am doing the procedure part A, don’t ask me about part X,” he said.
Those who organize the live surgery events should make sure that everybody in the operating room has experience: the surgeon and everyone else in the operating team, the moderator, the technicians and the camera crew. A backup set of instruments and IOLs should be ready to avoid unnecessary interruptions.
“You obviously need the patient to be very comfortable doing the procedures, and you want surgery to be seamless, with no downtime or waiting time for the audience as well,” Devgan said.
Thinking ahead of potential complications and how to approach them is always important, but even more so in the context of live surgery events, Teymoorian said.
“There is some data out there saying that the rates of complications for live surgery are higher than in regular practice. Also, the wording, the way you will explain what is happening, is something that needs to be thought out ahead of time to avoid stressing out the patient,” he said.
“If complications occur, the most important thing is to stay calm. All surgeons at some point experience complications, and you will be able to show the audience how you recover from this. Just give that patient the same high level of care that you would want,” Devgan said.
Ethical concerns
How a surgeon manages a complication during live surgery could be even more educational than the primary surgery, according to Ayres. However, a complication may not be so easy to manage under the stress of a live performance.
“You’re already under stress in a new environment, and then, when you have a complication, you’re even further outside your comfort zone. This might not be the time to have a camera on you. On the other hand, I know several doctors who would probably perform equally well under pressure than in their own environment, so it is really hard to judge,” he said.
What he definitely does not like is the buzz that is often created about complications.
“It becomes the talk of the town, gossip around Dr. X who broke the posterior capsule. And you forget that behind that screen there’s a patient who had a complication and may have further downstream issues,” Ayres said.
Among patients, there are those who are aware of the risks and benefits of what they are undergoing and knowingly offer to be part of an educational event, but it is not rare nowadays to have patients who are also motivated by the excitement of gaining popularity on YouTube and social media.
“They want to be the one on the screen with thousands of people watching them. They think it is fun and downplay some of the risks of surgery. But it’s not a video game, it’s not a social media post — it’s surgery. If something goes wrong, that’s going to impact them potentially for the rest of their lives,” Ayres said.
In consideration of these issues, questions have been raised regarding the benefits and risks of live surgery sessions. Medical associations across specialties have issued recommendations and guidelines, stressing the importance of intent and motivation. In a 2020 advisory opinion of 2020, the American Academy of Ophthalmology stated that ophthalmologists should carefully assess their motivations “to ensure that participation in the live surgical event is primarily for educational purposes and is not unduly influenced by a commercial or industry relationship, the potential for increased professional reputation/recognition or surgical acumen, or the potential for publication.”
“There comes a point where maybe the focus is no longer on education and patient safety, and the focus becomes more on the coolest new lens or technology or showing off the latest, greatest phaco technology,” Ayres said. “You can make a commercial, that’s fine, but doing it through live surgery may have us a little off base as to what our priorities should be.”
All in all, live surgery is a mixed bag: It is the best way to educate surgeons, but it is also a slippery slope where surgeons could easily lose focus.
“The educational benefits of live surgery, I think, are tremendous, as long we have got our heart in the right spot ... as long as the focus is really education and patient care,” Ayres said.
Near-live surgery alternative
In addition to the challenges and ethical concerns that surround refractive surgery, Oliver Findl, MD, MBA, FEBO, highlighted an inherent limitation of live surgery as a learning tool: the length of some procedures, with many dull moments, especially in more complex or combined cases.
“Then you have to change in and out of the operating theater, losing continuity, or you try to communicate with the surgeon. But not all surgeons like to be asked questions while they are operating,” he said.
Because of these issues and fear of complications, complex cases are often avoided, and many live surgery events present repetitive, standard cases in which the focus is mainly on the product.
As a chairperson or member of the panel sitting in the hall, Findl often experienced difficulties in leading the discussion with the surgeon at the end of the procedure.
“Usually, the surgeons come out of the operating theater in a room that is empty with a lot of echo. They don’t understand the question, we don’t understand the answer, and you don’t really have a good discussion. You have a very basic, simple discussion because of technical communication issues,” he said.
The European Society of Cataract and Refractive Surgeons, of which Findl is currently the president, proposed at this year’s meeting a new model called “near-live surgery.”
“A few months before the congress in Vienna, an ESCRS film team went to nine surgeons in five countries and filmed one surgery that was planned beforehand. We recorded the normal surgical video, and then we had two additional cameras to film the whole procedure, with the surgeon explaining it step by step,” Findl said.
The videos were then edited by Findl and the ESCRS, cutting uninteresting sections. All the surgeries were therefore reduced to 8 to 10 minutes, compressed and focused on what was thought to be most educational.
“The surgeons who did the operations were in the panel at the congress. Each of them did a short presentation, just three or four slides on the preoperative diagnostics. Then the video ran with the original narration, and at the end we could ask questions,” he said.
This format may lack the thrill of the unexpected complication, but it is more educational, in his opinion, and allows for more cases to be discussed within the allotted time frame.
The session in Vienna was attended by about 2,500 people who mostly stayed in the room the entire time.
“We didn’t have a formal feedback, but several attendees told me they enjoyed the opportunity to see the more complex and combined cases, such as corneal and cataract surgeries or glaucoma and cataract surgeries. They said that the variety of surgeries was more interesting and that it was more educational, more compact, with more time for a good discussion, with the surgeon in the room and no communication issues,” Findl said.
Companies were not in the operating theater during surgery and had no influence on the cutting and editing of the videos, which was solely done by the ESCRS.
“The companies originally were a little uneasy about that, but then I told them, ‘Why worry? These are surgeons you know very well, who have known your product for many years,’ and they eventually agreed with me on these points. Of course, we made very clear who the sponsors were with total transparency,” Findl said.
With this new format, the focus is more on education, and the surgeons remain within their comfort zone, with fewer risks for the patients and greater independence from the sponsors.
For future congresses, slight changes will be made, such as reducing the cases to eight, to allow for a more relaxed schedule. Four of them will be performed by surgeons in the country that hosts the meeting and four from other countries.
This year, both the filming and editing were done “in the family” on a voluntary basis, and all the money that came in from sponsors went to charity. But even taking into account a professional film crew, the honoraria of the editors for the substantial number of hours involved, plus the traveling, near-live surgery should turn out to be less expensive than the live surgery format, Findl said.
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- References:
- Advisory opinion – live surgery. https://www.aao.org/education/ethics-detail/advisory-opinion-live-surgery. Published Sept. 18, 2020. Accessed Nov. 20, 2023.
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- For more information:
- Brandon D. Ayres, MD, of Wills Eye Hospital, Philadelphia, can be reached at bayres@willseye.org.
- Uday Devgan, MD, of Devgan Eye Surgery, Los Angeles, can be reached at devgan@gmail.com.
- Oliver Findl, MD, MBA, FEBO, of the department of ophthalmology, Hanusch Hospital, Vienna, can be reached at oliver@findl.at.
- Savak “Sev” Teymoorian, MD, MBA, of Harvard Eye Associates, Laguna Hills, California, can be reached at steymoorian@harvardeye.com.
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