Editing Colonoscopy technique (section)

== Looping ==

* Clues that a loop has formed:
** Loss of one to one relationship
** Paradoxical movement
** Controls feel jammed up - not working properly
* Sigmoid looping
** Abdominal pressure can be helpful if the sigmoid loops anteriorly, close to the abdo wall
** Don't ignore pain
** Alpha looping
*** Suspect this if insertion is very easy through to descending colon
*** Push on to descending/splenic flexure before trying to straighten (don't want to straighten half way round an alpha loop - wait until fully formed then pull back)
** The 'N' loop
***
*** Steps:
**** Use some water and gentle pressure, but don't push through blanching
**** Pull back and deflate to shorten the sigmoid. This should allow direct passage into descending colon.
**** Pull back with clockwise shaft twist
**** Change to slimmer/paediatric scope
**** Abdominal pressure
**** Change patient to supine or right lateral
*** Stop it from forming in the first place by using less air and less push in the sigmoid
** Spiral loop
*** Actually a good thing because it means no acute angle at sigmo-descending junction
*** The 'alpha maneuvre' (counter clockwise torsion in the sigmoid) can be used to create a spiral loop
*** Need to remove it at some stage - mostly at splenic flexure. Often, once you get to about 90cm with a spiral loop, you can pull back to about 50cm to straighten it.
*** Straighten via pull back and strong clockwise twist (twist alone would just change it into an N loop. If you pull back and just move back without releasing loop, apply more twist.
** S loop
*** This occurs in the setting of a long sigmoid. A flat S shaped loop may form with no spiral configuration. Need to get past the splenic flexure, angulate the tip and then pull back.
* Splenic flexure
** Aim to reduce scope to 50cm after hooking around splenic flexure (it can go back as far as 40cm if there is a lax phrenicocolic ligament). If proximal colon is hard, it's probably because the splenic flexure hasn't been reduced to 50cm.
** Hand pressure does not help here due to depth of colon
** Variable fixation due to phrenicocolic ligament
** After going around splenic flexure:
*** Reduce scope to 50cm
*** Stiffen scope to stop sigmoid re-looping
*** De-angulate scope a little to allow it to smoothly run around the outside of the bend
*** Deflate colon
*** If still getting resistance, hand-pressure at sigmoid
*** Clockwise torque to stop sigmoid loop
*** Slow push
*** Change position (if stuck for about 60 seconds)
** Reversed splenic loop can occur - needs to be de-rotated first (counterclockwise)
* Transverse mesocolon
**
** To reach hepatic flexure:
*** Pull back to lift up transverse loop
*** Deflate
*** Try counterclockwise twist - changes splenic flexure path more medially
*** Try hand pressure in the upper abdomen or over sigmoid
** Gamma loop
*** Forms in a long redundant transverse colon
*** Hard to remove due to size and because there are no anchoring points to angulate the tip
*** Generally necessary to push on to caecum with the loop in place
*** Can sometimes be removed with combined withdrawal and very strong twist (usually anticlockwise)
* Hepatic flexure
* Ascending colon
** Looping preventing reaching caecum - try sigmoid pressure, then repositioning onto back
** Try fully reducing loops by withdrawing back to splenic flexure at ~50cm