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The death of a patient who was operated upon by a Japanese surgeon as part of a live surgery workshop at the All India Institute of Medical Sciences ( AIIMS ) in Delhi last week has rekindled a debate on the ethics of organizing such workshops and the rights of patients on whom the procedures are carried out.At the workshop on July 31, part of the 23rd annual conference of the Indian National Association for Study of the Liver, hosted jointly by AIIMS and the Army Research & Referral Hospital, New Delhi, over a hundred surgeons watched as Dr Goro Honda, from Japan ’s Tokyo Metropolitan Cancer and Infectious Diseases Center, performed a laparoscopic liver resection at AIIMS. He was assisted by an Indian team led by Dr Sujoy Pal , an associate professor in the gastrointestinal surgery department of AIIMS.Laparoscopic liver resection involves the removal of the liver or a portion of it through three or four keyhole-sized incisions in the stomach.The surgery, which started at 9am, was being broadcast live to a hall full of surgeons. Honda’s patient was 62-year-old Shobha Ram — a labourer who had developed liver cirrhosis after a hepatitis B infection. Ram was transferred to AIIMS from GB Pant Hospital which has a reputed GI surgery facility headed by Dr Anil Agarwal . Some time into the procedure, massive bleeding occurred and surgeons struggled to stanch the flow of blood.Despite suggestions that the team resort to an open surgery, Honda continued with the laparoscopic technique, relenting only after seven hours of surgery. The live video feed to the audience was terminated and the patient shifted to the intensive care unit, where he died 90 minutes later.Live surgery demonstrations have raised questions about the propriety of exposing a patient to a situation where the operating surgeons are intent on showcasing their skills live before an audience. In the United States, after the death of a patient in a similar workshop in 2006, some medical bodies have banned such operations.This incident at AIIMS has only added to the controversy. Questions are now being raised about the ethical and procedural aspects of the fatal workshop. Did the organizers take permission from the Medical Council of India (MCI) to allow a foreigner to conduct surgery? Could Ram have been saved if the surgeon had not insisted on continuing with the laparoscopic technique despite the bleeding? Was a post-mortem audit of the laparoscopic procedure carried out?Many questions relate to the pre-surgery diligence. Was Ram’s assent sought to have him subjected to a demonstrative procedure carried out by a foreign surgeon and assisted by a team with little or no experience in the technique? (It is now learnt that given the inexperience of the AIIMS GI surgery department in laparoscopic liver resection, it would have been more prudent to have assembled an experienced team from outside the hospital for the workshop.)Was the patient selection process done meticulously? Was laparoscopic resection the most suitable procedure for treating Ram’s condition or did the need to find a patient for the workshop override patient interest?When contacted, Dr Peush Sahni, head of the AIIMS GI surgery department, said that Ram’s attending doctors had carried out a detailed preoperative assessment to ascertain the feasibility of removing the tumour surgically. Sahni said haemorrhage is a known complication of the procedure and that the mortality rate globally of laparoscopic resection in patients with cirrhosis is 5-10%. However, a questionnaire on the incident emailed to him remained unanswered. And until questions are asked and answered, perhaps the debate on live surgeries will only get more heated.