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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2021  |  Volume : 26  |  Issue : 6  |  Page : 370-373

Live case demonstrations are essential for the success of pediatric urology meetings in India

1 Pediatric Surgery, Pediatric Urology & MAS, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
2 Pediatric Urology, SRIHER, Chennai, Tamil Nadu, India
3 Pediatric Surgery, Gandhi Medical College, Hyderabad, Telangana, India
4 Pediatric Surgery, Niloufer Hospital, Hyderabad, Telangana, India

Date of Submission19-Jun-2020
Date of Decision26-Jul-2020
Date of Acceptance21-Apr-2021
Date of Web Publication12-Nov-2021

Correspondence Address:
Dr. V V S Chandrasekharam
Ankura Children's Hospitals, Road No 12, Banjara Hills, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.JIAPS_200_20

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Purpose: The purpose of the study was to survey the opinion of delegates attending national pediatric urology meeting regarding live case demonstrations (LCDs) to see whether these can be replaced with taped case demonstrations (TCDs) in future.
Methods: A questionnaire-based survey was conducted at the end of the 3-day annual conference and live operative workshop in pediatric urology. Apart from general data such as age of the respondent and type of practice setting, four key questions on LCDs with yes/no responses included: would you have attended this meeting if there were no LCDs? Are unedited videos (TCDs) as effective as LCDs for teaching? Do you think LCDs should be continued? Would you allow your child to be operated in LCD by an expert? For question 3, the outcomes were compared between junior surgeons (<45-year-old) and senior surgeons (>45-year-old).
Results: On analysis, 88/140 (62%) respondents (95% confidence interval [CI]: 54%–70%) said that they would not have attended the meeting if there were no LCDs; 70/139 (50%) respondents (95% CI: 42%–58%) felt that TCDs may be an effective alternative to LCDs; 129/144 (90%) respondents (95% CI: 83%–94%) felt that LCDs should be continued. For question 4, 101/129 (79%) said they would allow their child to be operated in LCD by an expert, while 28 (21%) did not agree for their child to be operated in LCD. There was no significant difference between junior and senior surgeons regarding support for LCDs (P = 0.15).
Conclusions: In the Indian scenario, LCDs were favored as an essential part of pediatric urology meeting, attract more participation, and are likely to be important for the success of the meeting.

Keywords: Case, demonstration, live, pediatric, urology

How to cite this article:
S Chandrasekharam V V, Babu R, Srinivas S, Rao N B, Kumar A N. Live case demonstrations are essential for the success of pediatric urology meetings in India. J Indian Assoc Pediatr Surg 2021;26:370-3

How to cite this URL:
S Chandrasekharam V V, Babu R, Srinivas S, Rao N B, Kumar A N. Live case demonstrations are essential for the success of pediatric urology meetings in India. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2022 Dec 3];26:370-3. Available from: https://www.jiaps.com/text.asp?2021/26/6/370/330362

   Introduction Top

Live case demonstrations (LCDs) are popular in pediatric surgical and pediatric urological conferences. These LCDs can provide excellent training opportunities, as they allow the audience to view an operation conducted by expert and renowned surgeons and have the ability to interact with them in real time. However, several ethical considerations and patient safety issues have been raised with this practice.[1],[2] In contrast, others feel that certain educational benefits associated with LCD cannot be matched with taped case demonstrations (TCDs), where a prerecorded unedited video is played and discussed.[3],[4] Several reports found that LCDs did not compromise patient safety or affect outcomes, especially when performed by experts.[5],[6] Most reports and surveys on LCDs have been from adult surgeons and adult specialists, with few studies focusing on pediatric surgical specialists. In the only published survey of pediatric surgeons, most International Pediatric Endosurgery Group (IPEG) members regarded LCD as an essential part of surgical education, and the majority of members were in favor of continuing LCDs.[7] We surveyed the opinion of delegates attending our national pediatric urology meeting regarding LCDs, and the results are presented here.

   Methods Top

A questionnaire-based survey was designed and conducted at the end of the 3-day annual conference and live operative workshop of Society of Pediatric Urology, subchapter of Indian Association of Pediatric Surgeons (SPU-IAPS), June 14–16, 2019 at Hyderabad, Telangana. The meeting program consisted of invited guest lectures, expert panel discussions, free paper presentations, and 2-day LCDs. Eleven pediatric urologic procedures were demonstrated live consisting of both open and laparoscopic procedures. Visiting surgeons from both India and abroad performed most (9/11) LCDs; only 2/11 LCDs were performed by local organizing faculty (VVS). We observed the following procedures for conducting the LCD: only experts in the field were invited as operating faculty; the planned operations for the LCDs were discussed over phone and e-mail, and any specific individual preferences for instruments/sutures/other equipment were addressed beforehand. Temporary MCI registration of the invited overseas faculty was obtained. One day before the LCD, all the prospective patients were examined and discussed in an expert panel before selecting the patients and allotting them to the operating surgeon for live demonstration. The local faculty was physically present in the operating room throughout the procedure to help in any local logistic issues. With these precautions, all LCDs were conducted smoothly, without any intra- or postoperative complications. The survey questionnaire was prepared in such a way so as to encourage maximum participation in the survey, by limiting the number of questions and using simple direct questions with only yes/no as the possible answers. Four questions were designed with the specific aim of knowing the views of the participants about LCDs. Apart from the general questions, the important questions that were used in the final analysis are shown in [Table 1]. The results were analyzed using statistical analysis where appropriate; Fisher exact test was used and P < 0.05 was considered statistically significant.
Table 1: Questions used in analysis

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   Results Top

The meeting was attended by 204 delegates from five countries (97% consisting of pediatric surgeons from India), of which 157 delegates (77% participation), including 21 lady surgeons and 25 trainees, filled the questionnaire. Half of the participants (77/157) were employed in an academic setting (about one-third of them also had private practice), while the rest half (80/157) of the delegates were in pure private practice. Most participants answered all questions, while some skipped a few questions. The responses to the questions are summarized in [Figure 1].
Figure 1: Bar diagram showing responses to four main questions

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  • Question 1: 88/140 (62%) respondents (95% confidence interval [CI]: 54%–70%) said that they would not have attended the meeting if there were no LCDs
  • Question 2: 70/139 (50%) respondents (95% CI: 42%–58%) felt that TCDs may be an effective alternative to LCDs
  • Question 3: 129/144 (90%) respondents (95% CI: 86%–94%) felt that LCDs should be continued
  • Question 4: Of the 129 respondents who wanted LCDs to be continued (response to question 3), 101 (79%) said that they would agree to subject their own child for surgery in LCD by an expert; of these, 15 (12%) said they would like to choose the expert who would operate on their child. The remaining 28 (21%) said that they would not allow their child to be operated in LCDs even by an expert.

To analyze if younger surgeons were more in favor of live workshops, the answer to question 3 was further analyzed by dividing the respondents into two groups based on delegate age: juniors (<45 years old) and seniors (>45 years old). There was no significant difference between junior and senior surgeons regarding support for LCDs, with 70/75 junior and 47/55 senior surgeons supporting LCDs (P = 0.15).

   Discussion Top

With popular attendance by delegates, many surgical conferences both in India and abroad advertise LCDs as one of the premier sessions offered. The benefits of LCDs include witnessing often difficult cases performed by expert surgeons (aided by expert assistants), interactive discussion that may provide insight not available in any text or video, and a sense of suspense that often commands the viewer's attention.[3] Earlier surveys have shown that most participants would like to incorporate what they observed in the LCDs in their own practice,[4] thus enhancing the importance of LCDs as learning tools.

According to our survey results, over 60% of delegates would not have attended the SPU-IAPS annual conference if there were no LCD in the schedule. This proves that LCDs play an important role in ensuring more delegate attendance for surgical meetings in India. This is further supported by 90% of the survey participants voting in favor of continuing LCDs in pediatric urologic meetings. Further, both young and senior surgeons demonstrated similar interest in LCDs. Although 50% of the participants felt that TCDs might be as effective as LCDs, given a choice, most (90%) would choose LCDs.

A critical question in deciding the unbiased opinion of delegates about LCDs is about consenting their own child to be operated in LCD. In a previous IPEG survey,[7] at least 50% of delegates would not consent for LCD in their own child. In contrast, in the present survey, 79% of participants would consent for LCD in their child, although some (12%) said that they would choose the specific surgeon who would operate on their child. Thus, it would seem that most Indian pediatric surgeons demonstrate a strong and genuine interest in LCDs and their benefits.

The ethical, moral, and safety issues of LCDs have recently been a topic of much controversy, owing to conflicts of interest between the surgeon, the patient, and audience. There are many concerns confronting the visiting surgeon when performing LCDs at a hospital outside of his/her own hospital. A previous survey demonstrated how anxiety levels experienced by surgeons operating at a visiting hospital were much higher than at the home institution.[8] Khan et al.[9] delineated further issues such as a lack of specific instruments, language difficulties, and jet lag causing problems for a visiting surgeon. The live discussion during LCD may distract the surgeon; the increased stress and distraction have already been shown to affect surgical performance,[10],[11] raising questions over the safety of live surgery. However, current evidence suggests that there is no added danger to the patient during live demonstration, in terms of complication rates and success of live procedures.[5],[6],[12],[13] Recently, Andolfi and Gundeti[13] reported that the outcomes of live robotic pediatric urology procedures performed at the author's home institution were comparable to their previously published nonlive case series. However, the situation is not comparable to our scenario, where most LCDs are performed by visiting surgeons from within and outside India. Overall, there remains strong support for live surgery, with many believing there is little difference between live surgery and teaching students in the OR.[10]

One more concern with LCD is obtaining informed consent from the parents/patients regarding participation in LCD. In addition, the host team should have the expertise to handle any intra/postoperative complications. They should also have the necessary back up to provide follow-up and ensure a successful outcome. To ensure safe and effective conduct of LCDs, several societies have issued guidelines for conducting LCDs. The European Association of Urology (EAU) published such comprehensive guidelines,[14] where a committee of experts developed a policy on how best to conduct live surgery at urologic meetings. This policy statement offered specific guidelines for the operating surgeons (including visiting surgeons), the local organizing committee, the audience, and the EAU with the aim of providing potential benefits to patients (patient safety, information, and an advocate to safeguard patient interest). The panel concluded that live surgery is an integral part of the dissemination of medical knowledge, and the EAU recognizes the educational role of LCDs at urologic meetings according to a clearly defined regulatory framework. LCDs must be performed by the “right” surgeon on the “right” patients in the “right” environment and with the “right” intentions. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery.[14]

The present survey group had nearly equal participation from academic and private practice settings, which gives further credence to the results. Our response rate of 77% is much higher than some previous surveys, where the response rate was only 25%.[4] Thus, although we feel our survey reflects majority opinion, the present study has several limitations. Being a survey, it is subject to many biases. Many of the people who attended the meeting may be interested in LCDs, so it may be a biased population. To maximize the participation of the delegates, we carefully chose a small number of direct questions, thus limiting the expression of true opinions. Moreover, a survey can only be subjective assessment, and comparative studies are necessary to evaluate the objective benefits of LCDs. Nevertheless, being the first of its kind from India, we hope this survey might provide insights toward understanding the important topic of LCDs.

   Conclusions Top

At least in the Indian scenario, most delegates attending national pediatric urology meeting seem to support LCD as an essential part of the meeting. LCDs seem to attract more participation in the meeting and are likely to be important for the success of a surgical meeting.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Dehmer GJ, Douglas JS Jr., Abizaid A, Berg JW, Day J, Hall R, et al. SCAI/ACCF/HRS/ESC/SOLACI/APSIC statement on the use of live case demonstrations at cardiology meetings: Assessments of the past and standards for the future. J Am Coll Cardiol 2010;56:1267-82.  Back to cited text no. 1
Smith A. Urological live surgery – An anathema. BJU Int 2012;110:299-301.  Back to cited text no. 2
Rao AR, Karim O. A benedictory ode to urological live surgery. BJU Int 2013;112:11-2.  Back to cited text no. 3
Elsamra SE, Fakhoury M, Motato H, Friedlander JI, Moreira DM, Hillelsohn J, et al. The surgical spectacle: A survey of urologists viewing live case demonstrations. BJU Int 2014;113:674-8.  Back to cited text no. 4
Mullins JK, Borofsky MS, Allaf ME, Bhayani S, Kaouk JH, Rogers CG, et al. Live robotic surgery: Are outcomes compromised? Urology 2012;80:602-7.  Back to cited text no. 5
Legemate JD, Zanette SP, Baard J, Kamphuis GM, Montanari E, Traxer O, et al. Outcome from 5-year live surgical demonstrations in urinary stone treatment: Are outcomes compromised? World J Urol 2017;35:1745-56.  Back to cited text no. 6
Dingemann J, Laje P, St Peter SD, Ure BM. IPEG survey on live case demonstrations in pediatric surgery. J Laparoendosc Adv Surg Tech A 2012;22:705-9.  Back to cited text no. 7
Duty B, Okhunov Z, Friedlander J, Okeke Z, Smith A. Live surgical demonstrations: An old, but increasingly controversial practice. Urology 2012;79: 11.e7-11.  Back to cited text no. 8
Khan SA, Chang RT, Ahmed K, Knoll T, van Velthoven R, Challacombe B, et al. Live surgical education: A perspective from the surgeons who perform it. BJU Int 2014;114:151-8.  Back to cited text no. 9
Jones JW, McCullough LB. Operative simulcasts: Patient's donations to surgeon's education. J Vasc Surg 2008;47:476-7.  Back to cited text no. 10
Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. The impact of stress on surgical performance: A systematic review of the literature. Surgery 2010;147:318-330, 330 e311-6.  Back to cited text no. 11
Seeburger J, Diegeler A, Dossche K, Lange R, Mohr FW, Schreiber C, et al. Live broadcasting in cardiac surgery does not increase the operative risk. Eur J Cardiothorac Surg 2011;40:367-71.  Back to cited text no. 12
Andolfi C, Gundeti MS. Live-case demonstrations in pediatric urology: Ethics, patient safety, and clinical outcomes from an 8-year institutional experience. Investig Clin Urol 2020;61:S51-6.  Back to cited text no. 13
Artibani W, Ficarra V, Challacombe BJ, Abbou CC, Bedke J, Boscolo-Berto R, et al. EAU policy on live surgery events. Eur Urol 2014;66:87-97.  Back to cited text no. 14


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  [Table 1]


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