Evaluation of the Educational Quality of the Top 30 Most Viewed Laparoscopic Distal Pancreatectomy Videos on YouTube

Abstract

Background:

Online surgical videos serve as useful adjuncts for surgical training. YouTube is a social media platform increasingly used for education. However, the educational qualities of these videos have not been proven. This study aims to review the topmost 30 viewed videos on laparoscopic distal pancreatectomy (LDP) on YouTube.

Methods:

A YouTube search was performed on August 1, 2020, using the term “laparoscopic distal pancreatectomy.” Inclusion criteria were LDP with or without splenectomy. Exclusion criteria were open or robotic distal pancreatectomy and radical antegrade modular pancreatosplenectomy. To grade the videos, we used a modified version of the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) 24 of the original 37 consensus statements were used in our study.

Results:

Twenty-nine of the top 30 most viewed videos were included (1 video was a duplicate). The overall mean view count and number of likes were 7195 (range 2322–39,927) and 17 (range 0–108), respectively. Thirteen videos (44.8%) were on LDP with splenic preservation. The mean conformity to the modified LAP-VEGaS was 9.3 (range 4–16) with a mean of 38.8% (range 16.7%–66.7%) of the criteria met. There was weak correlation between the number of views and the number of criteria met (ρ = 0.189, P < .05). Twelve videos (41.4%) described about staple line management, nine videos (31%) about tips and tricks to reduce postoperative pancreatic fistula, including drainage tube management, and three videos (10.3%) identified the common hepatic artery. Videos with no commentary had the lowest mean percentage of criteria met (24.6%).

Conclusion:

The topmost viewed LDP surgical videos have gaps in meeting the educational needs of a trainee. Video uploaders should be cognizant of the learning needs of surgical trainees.

Introduction

Distal pancreatectomy is indicated for patients with lesions in the pancreas' body and/or tail. Over the past decades, advances in minimally invasive techniques have improved surgical outcomes with lower postoperative morbidity compared to traditional open approaches for most abdominal surgeries.^1,2 A recent meta-analysis in 2022 has demonstrated that laparoscopic distal pancreatectomy (LDP) is associated with reduced intraoperative blood loss, overall postoperative morbidity, and length of hospital stay compared to open distal pancreatectomy (ODP).³ Oncological outcomes have shown to be comparable between LDP and ODP.⁴

However, the laparoscopic approach is associated with a learning curve, and surgeons need to surmount the learning curve to reap the benefits of LDP.⁵ In addition, surgical trainees are increasingly required and expected to partake in administrative tasks, undergraduate teaching, research and acquire essential nontechnical skills. Compliance with duty hours is also reinforced with emphasis on patient safety initiatives and increasing awareness of resident wellness.⁶ Technological advancement and digitalization have transformed surgical education and facilitated technical skill acquisition. Online surgical videos play an important role in surgical trainees' co-education and have added advantages of permitting self-learning at an individualized time and pace.⁷

YouTube (Google, Mountain View, CA) is a social platform founded in 2005 and has become increasingly popular for educational purposes. A survey conducted by Rapp et al. among trainees and specialists showed that YouTube was the most preferred source for surgical videos.⁸ YouTube stands out among other educational platforms for surgical videos as a free platform with viewership statistics and allows users to pose questions and generate discussion.⁹ However, edited videos uploaded on YouTube are neither peer reviewed nor undergo quality control. Common drawbacks in community-led uploaded surgical videos include the heterogeneity in educational content, misinformation, commercial intent, and the presence of conflicts of interest (COI).¹⁰

Recently, the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) were established because of this heterogeneity and unmet need to guide formatting and publishing of surgical training videos online.¹¹ While there have been studies reviewing the top viewed videos in laparoscopic cholecystectomy, laparoscopic major liver resection, laparoscopic appendicectomy, and transabdominal preperitoneal hernia repair,^12–15 there has been no study to date evaluating the quality of YouTube videos in LDP. Hence, this study aims to assess the top LDP YouTube videos.

Methods

Study selection and search strategy

A search was performed by the first author (M.T.) on August 1, 2020, on YouTube (https://www.youtube.com) using the keywords “laparoscopic distal pancreatectomy.” Videos were sorted based on the highest to lowest view count. No YouTube account was logged into to remove the confounding effect of personal search history on results. Filter was used to include “video” and exclude “channel,” “playlist,” and “movie.” No filter was used on the duration and definition of the video. Inclusion criteria were surgical videos on the conduct of LDP (either with splenectomy or splenic preservation) intraoperatively.

Exclusion criteria were videos with pictorial illustrations of the approach for LDP, other types of distal pancreatectomy (open or robotic), and radical antegrade modular pancreatosplenectomy (RAMPS), videos focusing mainly on the management of complications during LDP, and duplicate videos. A video with “any” English commentary (video and/or audio commentary) was included. No ethical approval was obtained as this study involved only public-domain videos. An arbitrary number of 30 was set for the videos with the highest view counts for analysis in our study as a high number of views may correlate with viewers' gauge of the educational utility of video.¹²

Data extraction and assessment of videos

General video characteristics like title, uploader, number of views, likes, comments, and subscribers, date of upload, country, length of the video (in seconds), maximum video resolution, subjective video quality, and the presence of verbal and written commentary were recorded. The maximum video resolution was recorded as the highest video resolution available on YouTube. Subjective video quality was defined as the ability to visualize key anatomical structures and was graded as poor or good. Videos were classified accordingly into three “types”: educational videos (defined as videos and/or their description that explicitly mentioned the purpose of the video was for teaching purposes), institutional videos (defined as videos where the hospital and/or affiliated university were mentioned in the videos), and individual surgeon videos (defined as videos where only the surgeons' names were mentioned).

The presence of verbal and/or written commentary was defined as the presence of the commentary in the English language. The educational utility of the videos was graded using the LAP-VEGaS. The LAP-VEGaS were adapted and modified to increase applicability for LDP.¹¹ Table 1 summarizes the components of the modified LAP-VEGaS used in our study, with 24 criteria (10 general and 14 procedure specific). The criteria were graded dichotomously with “1” and “0,” indicating meeting and not meeting the criterion, respectively. A score of “1” was given only if all clauses of each statement were met and were stated explicitly in the video, either through video or audio commentary. Conformity to grading criteria was defined as the number of criteria met out of 24 criteria.

Table 1.

Components of the LAP-VEGaS (Laparoscopic Surgery Video Educational Guidelines) Used to Grade the Laparoscopic Distal Pancreatectomy Videos

General criteria

(1) Patient consent for uploading of video
(2) Patient identity safeguard—no name, no birth date, no date of surgery, no patient face visible
(3) Doctor's name, affiliation, and country
(4) The title includes the name of the procedure—and this must be consistent with what is uploaded
(5) Statement of conflict of interest
(6) Patient position
(7) Port placement
(8) Specimen extraction site mentioned
(9) Mention of special equipment
(10) Satisfactory outcomes—patient recovery, etc.

Specific criteria for laparoscopic distal pancreatectomy

(11) Preoperative scan images shown
(12) Stapler used to cut pancreas
(13) The cartridge used for the stapler—mentions the color of the cartridge, staple height, company, etc.
(14) Spleen preserved
(15) Splenic artery and splenic vein management
(16) Mention of how the stomach was retracted
(17) Staple line reinforced with suture or glue
(18) Drain placement near staple line and tricks to reduce POPF
(19) Identification of CHA and safeguard for it
(20) Variation of anatomy described
(21) Blood loss mentioned
(22) Length of surgery mentioned
(23) Preoperative diagnosis
(24) Final histology mentioned

CHA, common hepatic artery; POPF, postoperative pancreatic fistula.

Two independent authors graded all the videos (M.T. and T.Z.J.T.). The authors were fourth-year medical students trained through suggested textbook readings, journal publications, and WhatsApp discussions to enhance their understanding of LDP. An interim review was conducted to ensure the accuracy of gradings with senior authors (S.A. and V.G.S.) after grading three videos, before completing the assessment for the rest of the videos. Open WhatsApp discussions clarified any discrepancy or uncertainty with the senior authors.

Statistical analysis

Categorical variables were expressed as number (%), and continuous variables were expressed as mean (range), unless otherwise specified. Spearman's rho was used to determine the correlation between the number of views and conformity to the modified LAP-VEGaS and duration of views and agreement to the modified LAP-VEGaS. All statistical analyses were performed with SPSS version 25.0 (SPSS, Inc., Chicago, IL).

Results

The top 30 most viewed videos were identified based on the inclusion and exclusion criteria. One video was a duplicate video with a different name and was eventually excluded. Twenty-nine videos were included in the final analysis. The overall mean view count was 7195 (range 2322–39,927), and the overall mean number of likes was 17 (range 0–108). Thirteen videos (44.8%) showed LDP with splenic preservation.

Video characteristics

Eleven educational videos (37.9%), 11 institutional videos (37.9%), and 7 individual videos (24.1%) are included. The overall video characteristics are summarized in Table 2. The videos had a mean duration of 529 seconds (range 189–1340 seconds). There was a mean of 1 comment (range 0–5), but 11 out of 29 videos had comments disabled. The maximum video resolution had a median of 480 p (range 240–1080 p). The subjective video quality had 22 graded as good (75.9%) and 7 as poor (24.1%). As for commentaries, 15 videos had verbal commentary (51.7%), 8 had written commentary (27.6%), 19 videos had at least one type of commentary in English (65.5%), and only 4 videos had both verbal and written commentary (13.8%).

Table 2.

Overall Video Characteristics of the Included Videos on Laparoscopic Distal Pancreatectomy (n = 29) Uploaded on YouTube

No.	Video title and link	Uploader	Video type	Views	Likes	Comments	Subscribers	Upload date	Country	Length of video (s)	Video maximum resolution	Subjective video quality	Verbal commentary	Written commentary
(1)	SAGES Top 21 Videos: Laparoscopic Distal Pancreatectomy https://www.youtube.com/watch?v=k61uZ6hRCjc	SAGES	Educational	39,927	108	0 (Disabled)	35,900	April 5, 2012	United States	1085	480p	Good	+	−
(2)	Azagra & Goergen: Laparoscopic Distal Pancreatectomy https://www.youtube.com/watch?v=hO-hvFFznas	Juan Santiago Azagra	Educational	18,912	45	1	445	October 2, 2013	Luxembourg	1117	240p	Good	−	+
(3)	Laparoscopic distal pancreatectomy with splenectomy https://www.youtube.com/watch?v=-ifEhCTHm_M	Raymund Andrew Ong	Individual	13,294	8	5	316	November 24, 2008	Philippines	473	480p	Poor	−	−
(4)	Laparoscopic Distal Pancreatectomy with Splenectomy https://www.youtube.com/watch?v=KBsRmJ196cg	Crumi4444	Individual	11,892	28	4	416	March 29, 2014	Japan	443	480p	Good	−	−
(5)	Cancer Of The Body Of +ancreas Techniques For Laparoscopic Distal Pancreatectomy In The Setting Of S https://www.youtube.com/watch?v=LW1H05FCOX4	SAGES	Educational	10,706	40	0 (Disabled)	35,900	September 15, 2014	United States	424	480p	Good	+	−
(6)	Laparoscopic distal pancreatectomy https://www.youtube.com/watch?v=SlgaXaM+dvk	The Oregon Clinic Liver and Pancreas Surgery Program	Hospital	9342	11	1	375	November 13, 2013	United States	360	1080p	Good	−	−
(7)	Step by step: laparoscopic distal pancreatectomy, splenectomy https://www.youtube.com/watch?v=a0cU-31IF80	גיא יולנא (Hebrew)	Hospital	9172	32	0	12	August 26, 2014	Israel	303	720p	Good	−	+
(8)	Laparoscopic Distal Pancreatectomy https://www.youtube.com/watch?v=v3_d7dXIOe4	SAGES	Educational	8709	24	0 (Disabled)	35,900	September 30, 2015	United States	600	720p	Good	+	−
(9)	Spleen preserving laparoscopic distal pancreatectomy https://www.youtube.com/watch?v=r2r6YeFpv4I	SAGES	Educational	7734	15	0 (Disabled)	35,900	September 15, 2014	Italy	306	480p	Good	+	+
(10)	Laparoscopic Distal Pancreatectomy: Kimura technique https://www.youtube.com/watch?v=9bGws10FSNk	Juan Santiago Azagra	Hospital	6875	35	1	445	March 7, 2018	Luxembourg	727	1080p	Good	+	−
(11)	V075 TECHNICAL ASPECTS OF A SPLEEN PRESERVING DISTAL +ANCREATECTOMY https://www.youtube.com/watch?v=sLtvj0b28no	SAGES	Educational	6252	33	0 (Disabled)	35,900	September 29, 2015	United States	335	1080p	Good	+	−
(12)	Laparoscopic distal pancreatectomy/splenectomy—UCSF Lawrence Way, MD https://www.youtube.com/watch?v=wcBSz+II0s4	Jonathan Carter, MD	Hospital	6040	8	1	696	April 23, 2011	United States	251	480p	Good	−	+
(13)	Laparoscopic Extended Distal Pancreatectomy & Splenectomy for Pancreatic Adenocarcinoma https://www.youtube.com/watch?v=iEZjmZTxlfk	SAGES	Educational	5879	22	0 (Disabled)	35,900	October 11, 2016	United States	416	480p	Good	+	−
(14)	Laparoscopic Distal Pancreatectomy for Insulinoma https://www.youtube.com/watch?v=+-qFent6nZ0	rbabor1	Individual	5500	5	1	14	October 2, 2010	Unknown	327	360p	Poor	−	−
(15)	Laparoscopic Distal Pancreatectomy with spleen preserving https://www.youtube.com/watch?v=+F6NyED25hQ	CasaCuraAbano	Hospital	5246	3	0	237	June 27, 2009	Italy	353	480p	Poor	−	−
(16)	Dr. +radeep Jain—+ANCREAS-Laparoscopic Spleen +reserving Distal +ancreatectomy https://www.youtube.com/watch?v=ML8Ji5rRpLc	DR +radeep Jain	Hospital	4257	8	1	607	February 13, 2014	India	1340	240p	Poor	−	+
(17)	Laparoscopic Distal Pancreactomy https://www.youtube.com/watch?v=WA7pJG3HrXs	drpolyp	Hospital	3662	8	1	593	May 13, 2010	United States	238	480p	Good	+	−
(18)	Laparoscopic Distal Pancreatectomy for Mucinous Cystadenoma https://www.youtube.com/watch?v=wb2vf0ZeWCw	SAGES	Educational	3638	2	0 (Disabled)	35,900	June 26, 2011	United States	527	240p	Poor	+	−
(19)	Laparoscopic Splenic and Vessel Preserving Distal Pancreatectomy https://www.youtube.com/watch?v=BBamX8v8bcI	SAGES	Educational	3602	9	0 (Disabled)	35,900	May 21, 2015	United States	443	1080p	Good	+	−
(20)	Laparoscopic distal pancreatectomy with splenectomy for large cystic neoplasm of the pancreas https://www.youtube.com/watch?v=tla-brkszic	Bullsnet	Hospital	3592	9	5	137	January 8, 2015	India	854	480p	Good	−	−
(21)	Laparoscopic distal pancreatectomy and splenectomy—lateral approach—Dr. Julie Hallet https://www.youtube.com/watch?v=isVQib5cUq8	Julie Hallet	Individual	3511	0	0 (Disabled)	35	July 9, 2016	Unknown	260	480p	Good	+	+
(22)	Laparoscopic distal pancreatectomy spleen preserving—UCSF Kimberly Kirkwood MD https://www.youtube.com/watch?v=O267vo9_v0c	Jonathan Carter, MD	Hospital	3161	2	1	696	April 23, 2011	United States	604	480p	Poor	−	−
(23)	LAPAROSCOPIC SPLEEN-PRESERVING DISTAL PANCREATECTOMY: A VIDEO PRESENTATION https://www.youtube.com/watch?v=0aqybJvBnqY	SAGES	Educational	2813	6	0 (Disabled)	35,900	September 30, 2015	Thailand	537	720p	Good	+	+
(24)	Lateral Approach to Laparoscopic Distal Pancreatectomy https://www.youtube.com/watch?v=RT-z_SOyZhM	Shiva Jayaraman	Hospital	2766	14	1	776	March 31, 2014	Canada	189	720p	Good	+	+
(25)	Laparoscopic Distal Pancreatectomy https://www.youtube.com/watch?v=AGGR9pzsJbg	Alexey Karachun	Hospital	2563	7	0	4170	April 17, 2014	Unknown	460	720p	Good	−	−
(26)	Laparoscopic Distal Pancreatectomy-Splenectomy for Insulinoma https://www.youtube.com/watch?v=v6AxfJJDstE	SAGES	Educational	2457	2	0 (Disabled)	35,900	June 27, 2011	United States	560	240p	Poor	+	−
(27)	Laparoscopic Distal Pancreatectomy for Cancer https://www.youtube.com/watch?v=dU1qAiskCNE	Baki Topal	Individual	2421	5	1	157	March 30, 2016	Unknown	546	1080p	Good	−	−
(28)	Laparoscopic Distal Pancreatectomy: Quick Tips 1 https://www.youtube.com/watch?v=0whgnbHhrh0	Shiva Jayaraman	Individual	2413	8	0	776	March 7, 2016	Unknown	478	480p	Good	+	−
(29)	Laparoscopic distal pancreatectomy for IPMN(5-Port) https://www.youtube.com/watch?v=ergW2IUvGeo	blackeyedsurg	Individual	2322	0	0	4	January 22, 2012	Unknown	777	480p	Good	−	−

+, Present; −, absent; SAGES, Society of American Gastrointestinal and Endoscopic Surgeons.

Conformity to the modified LAP-VEGaS

Table 3 summarizes the grading of individual videos using the modified LAP-VEGaS. The mean conformity to the modified LAP-VEGaS was 9.3 (range 4–16), with a mean of 38.8% (range 16.7%–66.7%) of criteria met. There was a significant but weak correlation between the number of views and the number of criteria met (ρ = 0.189, P < .05), and the duration of the video to a number of criteria met (ρ = 0.252, P < .05). Regarding procedure-specific criteria for LDP (n = 14), the mean conformity was 4.8 (range 1–10), with a mean of 34.2% (range 7.1%–71.4%).

Table 3.

Grading of the Educational Quality of Laparoscopic Distal Pancreatectomy Videos (n = 29) Using the Modified LAP-VEGaS (Laparoscopic Surgery Video Educational Guidelines)

Video number^a	Patient identity safeguard	Doctor's name, affiliation, and country	The title of the video includes the name of the procedure	Statement of conflict of interest	Patient position	Port placement	Specimen extraction site mention	Mention of special equipment	Satisfactory outcomes	Preoperative scan images shown	Stapler used to cut pancreas	The cartridge used for the stapler	Spleen preserved	Splenic artery and vein management	Mention of how stomach was retracted	Staple line reinforcement	Drain placement near staple line and tricks to reduce POPF	CHA identified and safeguarded	Variation of anatomy described	Blood loss mentioned	Length of surgery mentioned	Preoperative diagnosis	Final histology mentioned	Total criteria met (out of 24)	Conformity percentage (%)
1	1	1	1	1	1	1	1	1	0	0	1	1	1	1	0	1	0	1	0	0	0	0	0	14	58.3
2	0	1	1	0	1	1	1	1	0	0	1	0	1	0	1	1	1	0	0	0	0	1	0	12	50
3	1	1	1	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	1	0	5	20.8
4	1	1	1	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	0	4	16.7
5	1	1	1	0	0	1	1	1	0	1	1	1	0	0	1	1	1	1	1	0	0	1	0	15	62.5
6	1	1	1	0	0	0	0	0	0	1	1	0	0	0	0	0	0	0	0	0	0	0	0	5	20.8
7	1	0	1	0	0	0	0	0	1	0	1	0	0	0	1	1	0	0	0	0	0	0	0	6	25
8	1	1	1	0	0	0	0	1	1	0	1	1	1	1	0	0	0	0	0	0	0	1	1	11	45.8
9	1	1	1	0	0	0	0	1	1	1	0	0	1	1	0	1	1	0	0	0	0	0	1	11	45.8
10	1	1	1	0	0	1	0	1	1	1	1	0	1	1	0	1	1	0	1	0	0	1	0	14	58.3
11	1	1	1	0	0	0	0	1	1	1	1	0	1	1	0	1	0	0	0	0	0	0	1	11	45.8
12	1	1	1	0	0	1	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	1	1	7	29.2
13	1	1	1	0	0	0	0	1	1	1	1	1	0	0	1	0	0	1	0	0	0	1	1	12	50
14	1	0	1	0	0	0	0	0	0	0	1	0	1	1	1	0	0	0	0	0	0	1	0	7	29.2
15	1	1	1	0	0	1	0	0	0	1	1	0	1	1	0	0	0	0	0	0	0	0	0	8	33.3
16	1	1	1	0	1	1	1	1	0	0	1	1	1	1	1	1	0	0	0	0	0	1	0	14	58.3
17	1	1	1	0	0	0	0	1	0	1	1	0	0	0	1	1	1	0	0	0	0	1	1	11	45.8
18	1	1	1	0	0	0	1	1	0	1	1	0	0	0	1	0	1	0	0	0	0	1	0	10	41.7
19	1	1	1	0	0	0	1	1	1	1	1	0	1	1	0	1	1	0	0	1	1	1	1	16	66.7
20	1	1	1	0	0	1	1	0	0	1	1	0	0	0	0	0	1	0	0	0	0	1	0	9	37.5
21	1	1	1	0	1	0	1	1	0	0	1	0	0	0	0	1	0	0	0	0	0	0	0	8	33.3
22	1	1	1	0	0	0	0	0	0	0	1	0	1	1	1	0	0	0	0	0	0	0	0	7	29.2
23	1	1	1	0	0	1	1	1	0	1	1	0	1	1	0	0	0	0	0	0	0	1	1	12	50
24	1	1	1	0	1	1	0	0	0	1	1	0	0	0	0	0	0	0	0	0	0	1	0	8	33.3
25	1	0	1	0	0	0	0	0	0	1	1	0	0	0	0	0	0	0	0	0	0	0	0	4	16.7
26	1	1	1	0	0	1	1	1	1	0	1	1	0	0	0	1	1	0	1	0	0	1	1	14	58.3
27	1	0	1	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	0	3	12.5
28	1	0	1	0	1	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	1	0	5	20.8
29	1	0	1	0	0	0	0	0	0	0	1	0	1	1	1	0	0	0	0	0	0	1	0	7	29.2

Video number refers to the self-allocated number of the video as reflected in Table 2.

0, Absent; 1, present; CHA, common hepatic artery; POPF, postoperative pancreatic fistula.

Twelve videos (41.4%) described about staple line management, nine videos (31%) about tips and tricks to reduce postoperative pancreatic fistula (POPF), including drainage tube management, and three videos (10.3%) identified the common hepatic artery (CHA). Videos that had no commentary had the lowest mean percentage of criteria met (24.6%), while videos that had verbal commentary only had the highest mean percentage of criteria met (50.4%) (Fig. 1). Table 4 summarizes the overall statistics for assessing the educational quality of included videos using the modified LAP-VEGaS.

FIG. 1.

Relationship between the use of various forms of commentary with the mean percentage of grading criteria met.

Table 4.

Overall Summary Statistics of the Assessment of Educational Quality of Included Videos Using the Modified LAP-VEGaS (Laparoscopic Surgery Video Educational Guidelines)

Grading criteria	n (%)
General criteria
Patient consent	0 (0)
Patient identity safeguard	28 (96.6)
Doctor's name, affiliation, and country	23 (79.3)
The title of the video includes the name of a procedure	29 (100)
Statement of conflict of interest	1 (3.4)
Patient position	6 (20.7)
Port position	11 (37.9)
Specimen extraction site mention	10 (34.5)
Mention of special equipment	15 (51.7)
Satisfactory outcomes	8 (27.6)
Specific criteria for laparoscopic distal pancreatectomy
Preoperative scan images shown	14 (48.3)
Stapler used to cut pancreas	28 (96.6)
The cartridge used for the stapler	6 (20.7)
Spleen preserved	13 (44.8)
Splenic artery and vein management	12 (41.4)
Mention of how stomach was retracted	10 (34.5)
Staple line reinforcement	12 (41.4)
Drain placement near staple line and tips and tricks to reduce POPF	9 (31.0)
CHA identified and safeguarded	3 (10.3)
Variation of anatomy described	3 (10.3)
Blood loss mentioned	1 (3.4)
Length of surgery mentioned	1 (3.4)
Preoperative diagnosis	18 (62.1)
Final histology mentioned	9 (31.0)

CHA, common hepatic artery; POPF, postoperative pancreatic fistula.

Discussion

Technological advancements have transformed medical education and surgical training. Intraoperative videos serve as good adjuncts for surgical training. However, quality control is lacking, especially on nonmedical public domain platforms like YouTube. This is the first study to evaluate the top 30 viewed videos on LDP. We showed high view count does not correlate with conformity to the LAP-VEGaS and may not be the ideal material for surgical training.

It is by the assumption that a higher number of video views imply higher quality of the video. However, this is rarely the truth, as the “quality” of video may be determined in several ways, such as educational quality (defined by conformity to the modified LAP-VEGaS), duration of video, and video resolution. Our study showed a poor correlation between the number of views and conformity to the modified LAP-VEGaS. Our finding is similar to that of Rodriguez et al., who reviewed the top 10 listed videos (sorted by views) on laparoscopic cholecystectomy¹³; 9 of 10 videos failed to demonstrate a satisfactory critical view of safety score, and 5 videos were flagged for showing technical aspects, which were concerning for safety (e.g., cauterizing of the cystic artery without clipping).

Our study showed that only 12 videos (41.4%) described about staple line management and 9 videos (31%) about tips and tricks to reduce POPF, including drainage tube management. POPF is an Achilles' heel in pancreatic surgery and it is important for a trainee to learn the intraoperative technical strategies to reduce this risk. For example, slow compression of stapling device before firing of staple, selection of staple height, determining the exact place for parenchymal transection, and reinforcement of staple line with sutures or tissue glues are important strategies that should be included in a training video.

Furthermore, only 10.3% of videos identified the CHA. The incidence of aberrant hepatic artery (AHA) ranges from 15.1% to 24.8%.^16–19 It is concerning that only 10.3% of videos identified the CHA. Failure to identify AHA may result in iatrogenic vascular injury and postoperative hepatobiliary ischemic events.²⁰ About half of the videos demonstrated spleen preservation and this is important for two reasons. First, spleen preservation is more technically challenging than splenectomy. Higher view counts could be the result of surgical trainees accessing the videos to learn techniques for safe surgery to preserve the spleen. Second, spleen preservation videos should include tips and tricks for splenic artery preservation or ligation techniques.

High view counts on YouTube may not translate to good educational quality videos. YouTube is an online platform that is readily accessible to both medical and nonmedical professionals. Nonmedical professionals may not look into the intricacies of surgical dissection; more views increase the popularity of the video and may appear as “featured” videos.²¹ This subsequently translates to a cycle of higher view count, but does not reflect the utility or quality of the video. This limits the utility of YouTube surgical videos, and trainees need to be cognizant of potential errors in user-uploaded videos.²² However, this may not pose an issue for platforms that are targeted toward medical professionals, such as WebSurg (www.websurg.com) and MEDTube (https://medtube.net). Further studies may evaluate and compare the difference in quality across various educational platforms and YouTube.

The mean operating time for LDP has been estimated to be 2.5–3 hours.²³ However, the mean duration of the videos on LDP, which we included in our study, was 8.8 minutes (range 3.2–22.3 minutes). This approximates to almost a 1700% reduction in the duration of the operation. A 13-point survey conducted in the United States on 304 surgeons and trainees showed that surgeons were more likely to prefer longer videos when preparing for new (median 9) or infrequent cases (median 10) compared to routine cases (median 6).²⁴ No significant difference was observed between practicing surgeons and trainees.

Interestingly, however, shorter videos had higher audience engagement (defined as watch time divided by video duration) of 13.0% higher than long video formats (median 17.2 minutes, range 6.1–47.7 minutes), compared to short video formats (median 7.4 minutes, range 4.1–20.3 minutes). An important consideration in trimming of videos is whether there is any omission of difficulties encountered intraoperatively, such as dissection of dense adhesions or management of intraoperative bleeding. A study by Toolabi et al., including 74 laparoscopic sleeve gastrectomy YouTube videos, showed no difference in video duration between reliable and nonreliable videos (mean 22 minutes versus 18.5 minutes, P = .563);²⁵ reviewers determined the reliability of videos on meeting all key steps of the procedure.

Similarly, our study showed a poor correlation between video duration and conformity to the modified LAP-VEGaS. A trimmed video may not imply the omission of essential steps, but aims to improve audience engagement. However, we caution to conclude that short videos on LDP conform to educational quality guidelines, and viewers should exercise discretion and cross-reference to educational resources to verify the validity of the surgical procedure. It is possible that management of intraoperative difficulties, such as uncontrolled bleeding, was omitted.

While young surgical trainees are taught “textbook” surgical techniques in theory and practical (through experience in the operating theatre), intraoperative difficulties may not be frequently encountered; some trainees may not have the expertise to manage such situations. It is, therefore, more important for surgical training videos to include the management of intraoperative difficulties to improve educational value. Second, it is important to note that only one video (3.4%) reported the duration of operation. While the main purpose of YouTube surgical videos is to educate the technical intricacies of the procedure, knowledge of length of the operation will allow viewers to have a gauge on potential intraoperative complications and/or difficulties and know the “usual” operating time for that procedure.

It is interesting to note that the number of comments was minimal (mean 1, range 0–5), with 37.9% of videos with comments disabled. One of the key benefits of YouTube is the ability for viewers to post comments and/or questions, allowing two-way interaction between the uploader and viewer.¹⁰ This allows for academic discussion, exchange, and clarification on any misconception or potential error in the uploaded video. One of the main reasons for disabling comments is to avoid possible uncontrollable or undesired feedback from viewers.²⁶ However, this removes the two-way interaction of YouTube and may have other repercussions.

A study by Liao and Mak explored how bandwagon cues (more likes/dislikes) and interaction cues (enable/disable commenting) influence the perceived source credibility assessment (trustworthiness, goodwill, and competence).²⁷ Univariate analysis showed that videos that enabled comments appeared to be significantly more trustworthy than videos that disabled comments, regardless of the number of likes or dislikes received. This finding is important as our study found a significant proportion of videos with comments disabled; this may lead to unnecessary skepticism and impede learning. In the open community of the internet, it is also possible for comments to be irrelevant to the videos or even spread negativity.

A study on 150 educational YouTube videos using sentiment and qualitative analysis showed that the percentage of positive sentiments was generally higher compared to negative sentiments.²⁸ Themes of affective sharing (sharing of reflections, feelings, and inspirations), gratitude, and enjoyment (e.g., exchange of jokes with fellow learners and appearing to be enjoying the learning process) recurred among videos with positive sentiments. This helps to propagate a good learning environment among viewers and show appreciation to the uploader, promoting a learning culture. For instance, the video by Juan Santiago Azagra on LDP with spleen preservation (Table 2, Video 10) received a positive comment, “Today I have done my first laparoscopic pancreatectomy, following your tips. Thanks for continue teaching HBP surgeons in the world of laparoscopic approach.” This was received positively by the video uploader and encourages the culture of continuing medical education.

Only one video made a statement on COI. The Institute of Medicine first recommended the declaration of COI in 2009.²⁹ Since then, the International Committee of Medical Journal Editors (ICMJE) and Committee on Publication Ethics (COPE) have recommended that journal editors require published statements declaring authors' COI.^30,31 Selective reporting of favorable results has been shown to be strongly associated with COI due to selective reporting of particular outcome measurements or analyses.^32,33 Similarly, in publishing surgical videos, unfavorable outcomes may be edited from the final video in view of COI, limiting the usefulness of the video. To add, none of the videos analyzed in our study described whether the patient's consent was obtained for the video.

Under the Singapore Medical Council (SMC)'s Ethical Code and Ethical Guidelines (ECEG) 2016, visual or audio recordings of patients should not compromise patients' privacy, dignity, confidentiality, and anonymity. In addition, consent must be obtained for recordings, except when the recordings are an integral part of clinical assessment or treatment.³⁴ Similarly, since 1997, the General Medical Council (GMC) has legislated the need for consent for recordings to be made if they are not part of patients' care.³⁵ While the majority (96.6%) of videos safeguarded the patient's identity, it is unclear if informed consent was obtained.

Our study has its limitations. First, our study only reviewed the top 30 videos with the highest video counts; videos that were less viewed were not included and may have conformed to the educational quality criteria. However, we sorted the videos by views as a high number of views may reflect viewers' gauge of the educational utility of videos.¹² Videos uploaded later are also inherently prone to lower view counts and may be excluded from the study.

Second, the videos were graded by fourth-year medical students rather than postgraduate surgical trainees. However, they were provided adequate training and guidance by consultants in hepatopancreatobiliary and upper gastrointestinal surgery. Avenues were provided for clarification in the presence of doubt. This also helps to eliminate reviewer bias associated with advanced trainees. Finally, educational quality was defined as conformity to the modified LAP-VEGaS. The LAP-VEGaS were designed for grading surgical videos uploaded onto education platforms with 37 statements. There is a need for all clauses of each statement to be met before grading a score of “1.” For social media platforms like YouTube, the LAP-VEGaS may be too detailed and underestimate the educational utility of the videos.

Conclusion

The topmost viewed LDP surgical videos have gaps in meeting the educational requirements of a trainee. Video uploaders should be cognizant of the learning needs of surgical trainees.

Footnotes

Authors' Contributions

M.T.: data collection, investigation, statistical analysis, and article drafting. K.S.C.: statistical analysis, article drafting, and finalizing of the article. T.Z.J.T.: data collection and investigation. S.A.: supervision and revision of the article. V.G.S.: conceptualization, finalizing, and revision of the article.

Disclosure Statement

None of the authors have any COI to disclose.

Funding Information

This study did not receive any funding.

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