Practical Gastrointestinal Endoscopy

COLONOSCOPY AND FLEXIBLE SIGMOIDOSCOPY 149
but, if this fails, ‘specifically’ according to the results of local
palpation.
First, the transverse loop should be pulled up, then aspiration
collapses the colon and brings the flexure nearer still. It is at this
point that the final action to reach up to or around the flexure
may be ‘specific’ assistant hand pressure—empirically applied
to one of the following :
• left hypochondrium region (to push the whole loop toward the
hepatic flexure);
• mid-abdomen (to counteract the sagging transverse colon (Fig.
6.78);
• right hypochondrium (to impact directly on the hepatic flexure).
HEPATIC FLEXURE
Passing the hepatic flexure is helped by a sequence of actions:
1–Assess from a distance the correct direction around the flexure
because, after the tip reaches into it, it will be so close to the opposing
mucosa that it is very difficult to steer except by a predetermined
plan. At all costs avoid impacting the tip forcibly
against the opposing wall or it will catch in the haustral folds and
there will be no view at all.
2–Ask the patient to breathe in (and hold the breath), which lowers
the diaphragm, and often the flexure too.
3–Aspirate air carefully from the hepatic flexure, to collapse it toward,
but not actually onto, the tip as it moves around (Fig. 6.79).
4–Steer the tip blindly in the previously determined direction
around the arc of the flexure. Since the hepatic flexure is very
acute, it takes some confidence to angulate nearly 180° around
in the same direction without seeing well (Fig. 6.80). Use both
angulation controls simultaneously to achieve full angulation;
adding clockwise twist may be helpful.
5–Withdraw the instrument substantially for up to 30–50·cm to lift
up the transverse colon and straighten out the colonoscope (Fig.
6.81a,b) for passage into the ascending colon.
6–Aspirate air again once the ascending colon is seen, in order to
shorten the colon and drop the colonoscope down toward the
cecum (Fig. 6.81c).
Fig. 6.78–‘Specific’ hand pressure
may elevate the transverse
colon.
Fig. 6.79–Aspirate to shrink
the hepatic flexure towards the
scope.
Summary: passing the hepatic flexure
1–Assess the correct direction.
2–Ask the patient to breathe in.
3–Aspirate air to collapse the flexure.
4–Angulate the tip 180° around (often blindly).
5–Withdraw the instrument substantially.
6–Aspirate again to drop the scope down to the cecum.
Fig. 6.80–Suction toward, then
angle acutely (180°) around the
acute hepatic flexure.