Colonoscopy Training Tool

Welcome to

THE principles and strategies in colonoscopy

UNDERSTANDING the theory

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Learning Outcomes

This learning tool is to be used by learners with an existing basic knowledge of colonoscopy. Some experience (30-50) colonscopies performed is required to benefit from this app.

By the end of this module students should be able to:

• Describe the different components that make up a colonoscope and their functions

• Define the meaning of 'clockwise' and 'anticlockwise' torque

• Explain the indications for the use of 3 tools in a step by step approach:

1. Torque 2. Patient position change 3. Abdominal pressure

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Introduction

This module will provide the endoscopist with a basic toolbox for loop PREVENTION to ensure that: 1. The procedure is as comfortable as possible for the patient 2. The endoscopist has a strategic methodology for completing colonoscopy

REMEMBER: Before performing a colonoscopy, the patient should have received instructions for full bowel preparation and consent must be taken

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Colonoscope: KEY PARTS

Suction

Insufflation/ water

Left/right wheel

Up/down wheel

Tip

Shaft

Scope stiffener

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How to handle the colonoscope

The video illustrates the basic torque and wheel motions of the colonoscope

Use of a scope Guide

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Introduction to your colonscopy 'Toolbox'

There are 3 different tools that can be applied at different stages of the colonscopy to help the scope progress without loops. These should be attempted in the following order, moving onto the next tool within 5 minutes if the current tool fails

Torque

Patient position change

Abdominal Pressure

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Difficult stages of a colonscopy are the junction between rectum and sigmoid, splenic flexure and hepatic flexure (all fixed positions) Loop formation often takes place in the sigmoid colon and transverse colon

The next 3 slides will show how each of the 3 tools can be applied at each stage of the colonoscopy

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Step 1: Anal margin to sigmoid colon

Torque

• Gentle clockwise torque should be applied as soon as the rectum is intubated

• At the rectosigmoid junction, 180 clockwise torque should be applied to enable entry into sigmoid colon
• Continued clockwise torque should be applied upto the splenic flexure

Patient Positioning

• Procedure starts with patient in left lateral position
• Move the patient into supine position either at the rectosigmoid junction, or in sigmoid colon if torque fails
• Patient can be moved onto their right lateral in the sigmoid if still no improvement as it will also open up the splenic flexure

Abdominal pressure

• Pressure inwards and downwards towards the pelvis often helps during sigmoid insertion (A) (See video)

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Step 2: Sigmoid colon to hepatic flexure

Torque

• Continued clockwise torque should be applied upto the splenic flexure
• As you approach transverse colon from the flexure, anticlockwise torque should be applied in order to flip the scope downwards into the transverse colon. This can be continued upto the hepatic flexure

Patient Positioning

• As you approach the splenic flexure, patient can be laid supine with a raise of the right shoulder to open up the splenic flexure
• If this does not help then turn the patient fully into right lateral position
• Place the patient back into supine position to complete transverse colon

Abdominal pressure

• At the splenic flexure, pressure can be applied downwards to reduce the upwards looping of colonoscope (B)
• To shorten transverse colon and prevent a deep transverse loop, pressure can be applied inwards and upwards (C)

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Step 3: Hepatic flexure to caecum

Torque

• Slow clockwise torque will usually help to negotiate around the hepatic flexure under direct vision. Patient positioning is often required to help complete this step successfully

Patient Positioning

• Placing the patient prone (onto their front) with their arms outstrtched above their heads often helps to apply direct pressure to the abdomen and allow progression through the hepatic flexure into the ascending colon

Abdominal pressure

• Hepatic flexure to ascending: The positioning tool above can often enable passage through the hepatic flexure into ascending colon
• Ascending colon to caecum: Sometimes you may experience paradoxical movements at this stage and therefore cannot fully visualise the caecum. Upwards and inwards pressure on the caecum pushes it towards the scope. This combined with slow, gentle suction enables the caecum to be successfully intubated

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Toolbox Summary

1. Torque

2. Patient positioning

3. Abdominal Pressure

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QUIZ

Well done you have completed the module! Take the following test to assess your understanding

1. Match the parts of the colonoscope to the labels below. Click the Tick to reveal the correct answers

• Shaft
• Scope stiffener
• Insufflation/gas
• Suction
• Tip

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