Colonoscopy procedural skills and training for new beginners

Abstract

The incidence of colorectal cancer has been increasing in the developed world including South Korea and China. Colonoscopy allows for greater diagnostic specificity and sensitivity compared with other types of examinations, such as the stool occult blood test, barium enema, and computed tomography colonography. Therefore, in recent years, the demand for colonoscopies has grown rapidly. New beginners including primary care physicians may help meet the increasing demand by performing colonoscopies. However, it is a challenge to learn the procedure due to the long learning-curve and the high rate of complications, such as perforation and bleeding, as compared to gastroscopy. Thus, considerable training and experience are required for optimal performance of colonoscopies. In order to perform a complete colonoscopic examination, there were a few important things to learn and remember, such as the position of examinee (e.g., left and right decubitus, supine, and prone) and examiner (two-man method vs one-man standing method vs one-man sitting method), basic skills (e.g., tip deflection , push forward and pull back, torque, air suction and insufflation), advanced skills (e.g., jiggling and shaking, right and left turn shortening, hooking, and slide-by technique), assisting skills (e.g., position change of examinee, abdominal compression, breathing-holding, and liquid-infusion technique), and intubation techniques along the lower gastrointestinal tract. In this article, we attempt to describe the methods of insertion and advancement of the colonoscope to the new beginners including primary care physician. We believe that this article may be helpful to the new beginners who wish to learn the procedure.

Keywords: Beginner; Colonoscopy; Procedural skills; Training.

Figures

Figure 1

Comparison between normal-type colonoscope and long-type colonoscope (A), components of a colonoscope (B), control section; lateral and forward view (C, D). WL: Working length.

Figure 2

Posture of examinee and examiner (endoscopist). A: Left lateral decubitus position of the examinee; B: Two-man method; C: One-man standing method; D: One-man sitting method.

Figure 3

Basic techniques. A: Up deflection; B: Down deflection; C: Left deflection; D: Right deflection; E: Push forward and pull back; F: Air insufflation (simple closure of hole in the air/water infusion button; pushing button not required); G: Example of air insufflation; H: Air suction (pushing the button above air/water infusion button); I: Example of water suction (because air is invisible).

Figure 4

Advanced techniques. A: Jiggling; B: Effect of jiggling; C: Shaking; D: Effect of shaking; E: Right turn shortening; F: Left turn shortening.

Figure 5

Auxiliary techniques. A: Left lateral decubitus position; B: Supine position change; C: Right lateral decubitus position change; D: Prone position change; E: Abdominal compression. Left upper corner: Hepatic flexure compression; Right upper corner: Sigmoid colon compression; Left lower corner: Transverse colon compression; Right lower corner: Sigmoidodescending junction compression.

Figure 6

Schematogram of large intestine. Red dotted circles (rectosigmoid junction, sigmoidodescending junction, splenic flexure, hepatic flexure) and green dotted box (sigmoid colon) are potential difficult segments during the procedure.

Figure 7

Procedure description. A: For example, detailed left lateral decubitus position (the examinee with knees bent and pulled up); B: Perianal lesion; C: Various anal lesions; D: Red-out sign; E: Anal canal and distal rectum (Retroflexion view); F: rectum; G: Rectosigmoid junction; H: Sigmoid colon; I: Sigmoidodescending junction; J: Descending colon with horizontal fluid; K: Descending colon (fluid-removal view); L: Splenic flexure and spot; M: Comparison of splenic and hepatic flexures (barium study view); N: Transverse colon; O: Hepatic flexure and spot; P: Hepatic flexure and spot (retroflexion view); Q: Ascending colon; R: Cecum and ileocecal valve; S: Cecal base and appendix orifice; T, U, V: Terminal ileum (water filling view, indigocarmine-dye view, narrow-band imaging view, respectively).

Figure 8

Suggested algorithm for structured learning and training of colonoscopy in new beginners. 1Technical skills include methods for handling the colonoscope and resolving the loops, the ability to perform the colonoscopic examination adequately and in a reasonable amount of time; 2Cognitive skills include the indications and contraindications of the colonoscopic examination, the identification and classification of lesions, clinical decision-making based on findings, and adequate reporting of the colonoscopy; 3Examination-related skills include risk assessment of the patient and the safe method of administration of sedatives and/or analgesics. CIR: Cecal intubation rate; ADR: Adenoma detection rate.