How To Pass Sigmoid

Looping Colon

Fig. 5.9 Looping in the sigmoid colon.

a Straightening the loop by withdrawing the instrument and desufflating air (or suctioning insufflated air). b Straightening the loop using external hand pressure and withdrawing the instrument.

Fig. 5.9 Looping in the sigmoid colon.

a Straightening the loop by withdrawing the instrument and desufflating air (or suctioning insufflated air). b Straightening the loop using external hand pressure and withdrawing the instrument.

ness of mucosal vessels) are observed, or if there is increased resistance to advancement of the instrument and discomfort to the patient as these are signs of increased danger of perforation. Sharp kinks of the lumen can often be minimized or even eliminated by changing the position of the patient; the in-traperitoneal location of the mobile sigmoid colon makes this easier. In addition to the supine position, the right lateral position can also be helpful in some situations. Changing the patient's position does not increase risk and thus must always be attempted first before resorting to "blind" advancement of the instrument.

Bowing and Looping. An additional problem in passing the flexible sigmoid colon is bowing and looping of the endoscope. Disparity between the amount of colonoscope introduced into the rectum and the amount of advancement of the tip in the lumen is a sign that a loop is forming. In extreme cases, the instrument tip no longer moves proximally in the colon when advanced or even moves "paradoxically" in the direction of the anus. Pronounced looping in the sigmoid colon can result in the entire instrument being "used up" before reaching the descending colon; it can also create discomfort for the patient and increase risk of perforation, and, ultimately, make it impossible to complete the colonoscopy.

To counteract looping, the examiner can withdraw the instrument prematurely, and, if necessary, repeatedly, to the beginning of the loop. This can straighten the already intubated colon segment and allow gradual advancement proximally. Suctioning air when withdrawing the instrument can also be helpful (Fig. 5.9a).

If looping still cannot be entirely prevented or counteracted, and is impeding the continuation of the procedure, the use of external hand pressure can be helpful in fixing or "splinting" the sigmoid colon (Fig. 5.9b; see below). Using external compression preventively can often counteract looping (pro-phylactically). The optimal localization for applying pressure

Advancing Further to the Hepatic Flexure

Proximal Sigmoid ColonImage Sigmoid Colon Colon Alpha Loop

Fig. 5.10 Alpha loop technique.

a Alpha loop.

b-d Straightening the loop by pulling the endoscope back and rotating the shaft clockwise.

can be found by palpation. In rare cases of pronounced or atypical looping, brief use of radiography may be necessary for orientation.

A further option for straightening the lumen and making it easier to pass the proximal sigmoid colon and the sigmoid-de-scending junction is the so-called alpha-loop maneuver. Rotating the endoscope 180° counterclockwise in the sigmoid colon creates a loop (similar in shape to the Greek letter alpha; Fig. 5.10 a) which makes further advancement easier. The loop can be straightened after reaching the descending colon or the splenic flexure (by rotating the colonoscope clockwise). The procedure is detailed schematically in Fig. 5.10 b-d.

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