Practical Gastrointestinal Endoscopy

150
CHAPTER 6
(a)
(b)
(c)
Fig. 6.81–(a) When around the hepatic flexure and viewing the ascending colon … (b)… pull back to straighten
… (c)… and aspirate to collapse the colon and pass toward the cecum.
A combination of these maneuvers is used simultaneously.
Aspiration brings the hepatic flexure toward the tip until the
inner fold of the flexure can be passed, the colonoscope is withdrawn
(either by manipulation of the shaft or by the endoscopist
pulling the colonoscope out, using both hands simultaneously to
work the angulation controls) and the tip is steered maximally
around until it can be sucked down into the ascending colon. A
parallel has already been drawn between the ‘hook, withdraw
and clockwise twist’ situation in the transverse loop and hepatic
flexure and the ‘right twist and withdrawal’ method of shortening
the sigmoid N-loop at the sigmoid–descending colon angle;
the same instrument maneuvers apply to both, except that they
must be exaggerated at the hepatic flexure because of its larger
dimensions.
Position change is another trick that helps coax the colonoscope
tip into and around the hepatic flexure. Change the patient’s
position (to supine, prone or sometimes even right lateral positions)
if the usual left lateral position has been ineffective.
Using brute force rarely pays off, since the combined sigmoid
and transverse colon loops can take up most of the length of the
colonoscope shaft. With the instrument really straightened at
the hepatic flexure, only about 70·cm of the shaft should remain
in the patient; this is one of the situations where a distance check
helps to ensure a straight colonoscope and results in easy and
painless insertion.
Is it the hepatic flexure—or may it be the splenic? A final, embarrassing,
point is that if things are not working out at the hepatic
flexure after applying the various tips, the colonoscope may
actually still be at the splenic flexure. In a redundant colon it is