VM55 - Seton Placement Technique for Teaching

Purpose/Background: Effective teaching of surgical techniques and training within the operating room often relies on an apprenticeship model with graduated responsibility given to trainees as they progress through their training and build trust with surgical faculty. Challenges are faced when trainees are not able to work with the same faculty consistently or if case volume is not high enough to allow this trust to be built. We have noticed that consistently engaging and involving medical students in the operating room can prove to be difficult due to high variability in a student’s prior experiences in the operating room. The variability in experience in trainees has created a need to develop operative techniques that allow surgeons to operate with minimal assistance if needed as well as allow surgeons to teach trainees at an appropriate level.

Methods/Interventions: To address these concerns, we developed and described a method for placing setons for anal fistulas that colorectal faculty and fellows can use to operate without the need to rely on experienced assistants and to consistently instruct students and junior residents in the operating room. Our method is based on the following principles: 1) utilizing retractors to provide direct visualization for both trainees and supervising surgeons, 2) utilizing hemostats to secure sutures that can easily be removed inadvertently, and 3) applying hemostats to vessel loops such that trainees can easily tie knots to secure vessel loops at appropriate intervals while visualizing the knots they are tying.

Results/Outcomes: We found that utilizing these principles and our techniques allowed surgical faculty and fellows to supervise trainees comfortably due to the consistent direct visualization throughout the procedure. Our technique also allowed trainees to observe proper surgical technique and participate as appropriate. In addition, by utilizing retractors and hemostats as described, surgical fellows could progress through cases with either minimal assistance from trainees or alone with a surgical technologist.

Conclusion/Discussion: There are many ways to perform an exam under anesthesia and seton placement. When teaching, it is best to adapt to the level of the learner involved. While a colorectal surgery fellow should learn a wide variety of techniques, we have demonstrated a method adapted to instructing medical students and junior residents, focusing on the identification of fistula tracts and knot tying. We have also found that this technique works well when there is no trainee, and the surgeon is working only with a surgical technologist.