Medical Examiner

Live From the O.R.

The problems with broadcasting surgeries as they happen.

An operating room

Every eye in the Las Vegas hotel conference room was fixed on the screen, watching the action broadcast by satellite live from three time zones away. There were no wasted moves, no evidence of indecision. Then there was blood, like a geyser filling the screen. The audience gasped collectively.

In a minute, the bloodshed was over. Dr. Ted Lee  used forceps to grasp the offending artery, magnified enormously by the video camera that guided his surgery and broadcast in real time to hundreds of surgeons watching at the American Association of Gynecologic Laparoscopists annual meeting. Lee applied a current, and the artery was sealed.

The audience audibly relaxed.

Combining education with entertainment and patient care with promotion, live telesurgery is a fixture at surgical conferences and marketing campaigns by hospitals and medical device manufacturers. It’s natural that conference attendees want to see the best surgeons performing the most advanced procedures with the newest equipment. There’s no inherent reason why they need to watch it happen live—a narrated DVD would provide the same or better educational experience, with mundane sections eliminated and critical points in the surgery highlighted. But try telling that to conference organizers who know that live telesurgery is, rationally or not, a high point of many conferences.

In the beginning, surgery was a spectator sport. Nineteenth-century paintings show surgeons operating on patients with an auditorium of doctors looking on. Fortunately for the patient, antisepsis changed that practice. But the audience never left the operating room. Surgery continues to be taught to medical students, residents, and visiting surgeons who watch from glassed-off galleries or at the surgeon’s elbow, scrubbed into the operating room. (Remember the scenes in Grey’s Anatomy in which Meredith and O’Malley snack and chat in the room overlooking the O.R.? These rooms are increasingly rare because of concerns about confidentiality, but they can still be found in some hospitals.)

Traditional surgery, performed through an open incision, is difficult to televise because of poor visibility. Surgeons make the smallest incisions possible, and their work space is obscured by hands and instruments. Even a camera mounted on the bright lights illuminating the surgical field gets only an intermittent view of the organ being repaired.

With the advent of laparoscopy—surgery conducted using small instruments on narrow steel sticks placed through 1-centimeter incisions in the patient’s abdomen—the video image from an instrument-tipped camera that guides the surgery could be displayed in the next room or the next continent. Laparoscopic surgery allows for superior visualization of anatomic structures. Stick a microphone on the surgeon’s scrub shirt and park a satellite truck in the ambulance bay, and the operating room becomes a production studio.

Lee’s laparoscopic hysterectomy was typical: a challenging operation by a surgeon recognized for his expertise. Another surgeon serves as moderator, pointing out technical details of educational significance, asking the surgeon to explain tactical decisions and relaying questions from the audience for the surgeon to answer. All patients who participate in live telesurgery agree in writing prior to the operation and aren’t compensated. Surgeons typically receive no additional payment to televise their surgery, although they occasionally collect an honorarium from the conference. The invitation to operate live is a considerable honor, and the stakes are high. “If you screw it up,” notes Lee, “you will never be invited back.”

The entertainment value of live telesurgery is not lost on conference organizers, who spend significant sums for the production and satellite costs associated with each hourlong telesurgery. The American Association of Gynecologic Laparoscopists budgets approximately $50,000 for telesurgery costs for its annual meeting. Playing to the entertainment factor, AAGL added a competitive element to the broadcast last year by featuring a simultaneous telecast of two surgeons performing the same procedure to correct a pelvic defect—one operating with traditional laparoscopic instruments and the other using a da Vinci surgical robot. The surgeon with traditional instruments was quicker, much to the chagrin of the surgeon manipulating the robot.

Intuitive Surgical, maker of the $1.5 million da Vinci robot, has used live surgery to build hype for the robot, getting its message out to surgeons who might purchase the robot and patients who might demand robotic surgery. Patients seem to find live surgery as compelling as surgeons do, and as a recent New York Times story described, hospitals sponsor Internet broadcasts of surgery in order to reach potential patients.

Not surprisingly, the concept of surgery as entertainment has rankled some surgeons, who are disturbed by the shift in focus from the anesthetized patient to the surgeon performing the procedure, the resulting media production, and the company looking to create some buzz for its wares. Dr. Richard Satava, a general surgeon at the University of Washington in Seattle and a trustee of the Society of Laparoendoscopic Surgeons, worries about the doctor who is operating while interacting with the audience and thinking about the ongoing video production. “Is it ethical for a surgeon to be distracted from his operation,” he asks, “when he should be concentrating on the best interests of his patient?” Satava and others also worry about the risk that if something goes wrong, the patient (and her lawyer) could pin the error on the telecast.

This year, the Society of Laparoscopic Surgery will replace live telesurgery with narrated videotape at its annual meeting. Prompted by ethical concerns and the high cost of live telesurgery, it’s also testing other live-surgery alternatives such as “surgical surprises”—narrated videotaped presentations of surgical complications not disclosed prior to the presentation—or interactive sessions using Second Life to allow off-site participants to be part of the conference. OR-Live, a company built to serve this niche industry, also offers live narrations of previously recorded video as a cost-effective way to allow an online audience to interact with an expert without the production expense of live surgery.

For the same reasons we stay up late to watch the bottom of the ninth inning instead of waiting for highlights on the morning news, the taped surgeries don’t match the thrill of the live broadcasts. Although surgeons are ashamed to admit it, live telesurgery is more like NASCAR than baseball: We want to see the driver make the turn, but we’re also hoping for a wreck. Dr. Neeraj Kohli, a gynecologic surgeon at Brigham and Women’s Hospital in Boston, says surgeons “want to see someone screw up. They want to see that they aren’t the only ones who have complications.”

At least a dozen surgeons interviewed for this article mentioned the 2003 live telesurgery performed by gynecologic surgeon John Miklos, operating from outside Atlanta for the AAGL annual meeting in Las Vegas. Miklos encountered bleeding in an area in front of the tailbone that is notorious for its injury-prone blood vessels. For long minutes, he struggled to control the bleeding while audience members watched, transfixed. Finally, he shut down the cameras, converted to an open surgical approach, and stopped the bleeding. The patient was fine.

This fear of a mishap motivates surgeons to practice and prepare. Maybe watching surgery where the fear hasn’t been removed actually is the best education, short of scrubbing into the case.