This tract is about the alleged sins of the LSB (live surgical broadcast) at surgical conferences and workshops — aka surgery as spectator sport, which is the subject of an extended rant in the forthcoming issue of the journal Current Medicine: Research and Practice (Kumaran, Nundy). I propose deferring, but for a very short measure, any remarks on the ethics of the LSB, for the purpose of introducing you to Robert Liston, Esq, the first Professor of Clinical Surgery at the University College Hospital, London (anointed in 1835). It might be argued that, historically, the LSB owes its provenance to the popularity of this man’s performance. But first, a bit of a preface: in addition to its peculiar suitability as a Gothic locus, the Victorian operating theatre (with its symmetrically tiered seats rising on both sides and its small, central court or deck illumed by a large, low-hanging gaslight) was indeed a form of theatre. Where all surgical discourse happened, in constantives and performatives, as an accompaniment to the spectacle of live human vivisection, in the sight of students jostling in the galleries. Where the lecture-demonstration had all the elements of stagecraft thrown in, including, I daresay, art direction.

Always in his best Edinburgh scowl and his bottle green coat, double breasted shawl-vest, grey trousers, Wellington boots, and, on top of that, his blood stiffened apron, Liston’s popularity amongst the students was attributable, in equal measure, to his surgical swagger and his surgical velocity. He could, in the days before anaesthesia, amputate a leg in two-and-a-half minutes. He’d lurch over the restrained patient, pick out his favourite knife from his long, narrow leather case and declare to his students and colleagues in a cold, level voice: ‘Now gentlemen, time me’. He was a flourish of flashes: a dozen lightning strokes, and the limb would drop into the bucket of sawdust. Sometimes, to use both his hands, he’d hold the knife between his teeth.

His later oeuvre was marked by something of an unpleasant episode. It was the only time he amputated a limb under two-and-a-half minutes: the patient died subsequently from suppuration and hospital gangrene. In his showboating flourish, he also, accidentally, amputated the fingers of his assisting house surgeon, who also died from hospital gangrene (these were Pre-Listerian times). And, he managed to incise the frock coat of an esteemed associate standing right behind him, who dropped dead from a fright-induced fatal cardiac arrhythmia.

The LSB is surgery’s continuing thralldom to the live performance. It is an interactive session that has become the staple lead event at most conferences now. The whole nub of the thing is that an illustrious surgeon is called in to demonstrate her method and her surgical prowess to an audience of avid peers, live, via a video link. It is an audiovisual production, so the surgeon is all wired up and is usually required to provide a spoken account of the procedure as it happens or at least answer questions from the moderator or the audience. There’s a camera crew and multiple cameras in the OR, to capture disparate POVs. It works particularly well for videoendoscopic, laparoscopic and angiographic procedures, because, by definition, they’re done by looking at a screen. The broadcasts, increasingly, are on full 3D HD screens.

There has been a lot of righteous indignation expressed about the LSB, particularly after a patient undergoing laparoscopic liver resection at a live event in AIIMS died recently. Kumaran and Nundy’s critique is clear-eyed about the agenda of live surgery. In a sternly prescriptive way they pose the fundamental question upon which any discussion of the ethics of live surgery should take place: is participation in live surgical workshops harmful for the patients? The four hallowed principles of medical ethics must be courted individually in the course of answering that question.

Voluntas aegroti suprema lex: recognising the patient’s autonomy and right to self-determination. The informed consent is a pliant thing. What could be described as the best, latest care from a gora celeb surgeon coming in to operate could also be restated as an industry-paid outsider promoting a newfangled, possibly insufficiently tested widget or technique for the entertainment of other surgeons. Most ( desi ) patients will say yes to anything if the surgical charges are waived off.

Salus aegroti suprema lex: beneficence; all actions in the best interests of the patient. I remember watching the great Andrej Schmidt, the king of his species, at a live endovascular event, opening up an impossibly long segment of the blocked aorta and iliac arteries with almost bovine serenity and unerring precision. It was an archly brilliant performance, as was his wont. But at least a fourth of the audience kept asking themselves if the procedure was really indicated in an 84-year-old man with minor symptoms and severe, limiting, cardiac dysfunction.

Primum non nocere: non-maleficence; first, do no harm. Lustitia: justice; the morality of who gets what treatment. Kumaran and Nundy describe a complete abomination wherein the itinerant surgeon tried to resect an unresectable cancer of the pancreas unto a point of near exsanguination. The outcome was never reported to the participants in the workshop but they found out later that the patient was re-explored by the home team for intra-abdominal bleeding and died.

The LSB is a blood sport because calamity is what the spectators avariciously wish for. Once, at a live robotic aortic surgery event, we had this celebrity surgeon very sedulously looking for and securing the lumbar arteries (almost like a dog sniffing excrement) to prevent blood loss from the aorta upon incising it, and then enlivening the proceedings by injuring the vena cava (with all the guileless wrongness of a six-year-old walking in on his naked aunt). He then repaired it so unflappably that the audience very nearly genuflected.

But I need scarcely enlarge upon the unholy combination that is the itinerant celebrity surgeon who hasn’t seen the patient pre-operatively, who has to take the night flight out, and the organising committee that has promised to relay six live cases back-to-back to a bloodthirsty audience.

Then again, if truth be told, each one of those Latin bylaws is violated (at least in part) in our teaching institutions where instruction in surgery is given to residents; particularly when unsupervised residents operate in extremis in the middle of the night. That is just the nature of the beast. Surgical pedagogy is without doubt ‘a conspiracy against the laity’.

Curiously, it was Liston, in his waning years, who wrote this: ‘Surely the man to whose hands and knife the living flesh of a fellow-creature is to be submitted should expend some trouble in acquiring that manual facility that, controlled by the higher mental qualities, will conduce to his material safety.’ Amen.

Ambarish Satwik is a Delhi-based vascular surgeon and writer

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