EP147 - How Do We Improve Training for Anal Sphincter Repair?

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Purpose/Background: Sphincter repair represents an infrequently performed procedure in colorectal surgery. Many surgeons do not get sufficient training due to limited exposure during fellowship. It is however a skill that needs to be in the armamentarium of colorectal surgeons to be able to address complex obstetrical repairs and rectovaginal fistulas. Experience in sphincter injury management is crucial and a predictive factor for repair success. Specialized training is necessary to familiarize early-career colorectal surgeons with the procedure and develop the confidence to manage sphincter repairs. Mental imagery techniques represent a valuable approach to improve training outcomes. The objective of this study was to enhance knowledge, technical skills, and confidence in sphincter repair.

Methods/Interventions: A training session was conducted with a group of early-career colorectal surgeons with various levels of experience with sphincter repairs and without specific workshop preparation. During the supervised hands-on cadaver lab, detailed instructions and demonstration were provided initially to illustrate each step of the procedure. Subsequently, each participant had the opportunity to perform the procedure independently, as well as assist their colleagues in executing the procedure. Data on surgeons' previous experience, handedness, mental imagery history, and demographics were collected before the training session. Confidence in decision-making during repair and tissue handling was assessed using a 4-point Likert scale questionnaire pre-, post lab, and at eight weeks follow-up. The Mental Imagery Questionnaire (MIQ) evaluated the ability to visualize sphincter repair pre and post lab and at follow-up. Satisfaction with performance, learning, and teaching was assessed post lab and at follow-up. Incomplete questionnaires were excluded.

Results/Outcomes: Seven female, right-handed surgeons participated and 42,9% reported to have a history of mental training/imagery or meditation. The average number of previously performed sphincter repairs was 3 ± 4.1 with a median of 1. Post lab, 83% of the participants reported that the cadaver lab was helpful with a median satisfaction level of 5/5. Dissection and sphincter mobilization, as well as anatomy and tissue planes were stated to be the most difficult portions to replicate. Five complete sets of questionnaires were included in the analysis of confidence and MIQ. Confidence increased significantly post lab compared to pre lab in general and regarding decision making (p= .03 and p= .03, respectively), but not for tissue handling (p= .06). The confidence level did not change significantly eight weeks later (p= .50, p= .50, and p= .13, respectively). Recall of key steps during the follow-up did not change the confidence level (p= .50, p= .75, and p= .50, respectively). Mental Imagery improved significantly pre- and post lab in 6/7 (85.7%) evaluated aspects including teaching someone else by taking them through the procedure (p= .03) but did not change significantly at follow-up.

Conclusion/Discussion: Targeted training with the utilization of mental imagery techniques, observing, descriptive teaching and hands-on training in a cadaver lab helps improve familiarity with anatomy. This learning technique is a practical alternative to aid in teaching anal sphincter repair. It builds a necessary confidence level in performing uncommon anorectal procedures and could be applied to other infrequently performed anorectal procedures.