Hepatic Flexure Intubation
When the transverse is correctly passed and straightened by pull-back maneuver and complete air aspiration, the tip of the colonoscope approaches the hepatic flexure (Fig. 1) free of any friction with the colonic wall.
Fig. 1: when the transverse is correctly passed, the tip of the scope approaches the hepatic flexure
The patient is in supine position, as for the intubation of the transverse colon (fig. 2).
First, the endoscopist checks that both advancement and retraction of the colonoscope correspond to the one-to-one effect. Then the tip is slightly advanced over the fold between the transverse and the ascending colon, with the possible aid of the nurse through a manual compression below the sternum (Fig. 3).
Fig. 3: to pass the hepatic flexure the tip of the scope should reach or slightly pass over the fold between the transverse colon and the ascending colon (B – yellow dots).
Once reached the angle, the endoscopist flattens the fold by a strong left-deflection of the tip and a slight left-steering of the shat of the scope, transmitted to the tip moving the handle to the left of the chest (Fig. 4)
Fig.4 : the hepatic flexure is passed with left-angulation of the tip (A), followed by a left-steering of the colonoscope (B) applied by the endoscopist by simply moving the scope handle to the left of the chest (C).
Following this maneuver (hang and turn over) the tip of the scope engages the distal ascending colon; a counter-rotation of the chest to the right further flattens the hepatic angle and stabilize the colonic lumen allowing the progression to the proximal ascending colon (Fig. 5).
Fig. 5: the counter-rotation to the right applied by the movement of the scope handle (A), stabilizes the lumen of the ascending colon (B) and favors the progression into the proximal ascending colon (D).
Sometimes, the hepatic flexure is hard to pass; this is the case of obese patients, or patients with wide sigmoid loops, in which despite the shortening of the colon the curve tends to recur. In the first case it is useful to put the patient in the prone position to obtain a compression on the whole abdomen (fig. 6).
Fig. 6: in passing the hepatic flexure it is sometimes useful to put obese patients into prone position.
When the attempts at passing the hepatic flexure cause a paradox effect (that is the pushing force exerted by the nurse moves the scope backward, away from the flexure), the endoscopist can reset to minimum the stiffness of the scope if using a variable stiffness colonoscope, or position the patient on the left decubitus to modify the opening angle of the hepatic flexure (fig. 7). If the hepatic flexure is characterized by a very sharp angle (Fig. 7 B), such as in the case of a ptosic transverse colon, the attempts at progression are frustrated by the re-occurrence of sigmoid loops. In such situations, the supine position does not modify the hepatic angle significantly, whereas the left lateral decubitus (Fig. 7 C) favors the opening of the angle (Fig. 7 D), that can be more easily intubated.
Fig. 7 A-D: to widen the hepatic angle, the patient should be rotated on his/her left side (C). Due to the gravity that drags and straightens the transverse colon, the angle width of the hepatic flexure (H) is modified (green dot). As a comparison, above (A and B) the hepatic flexure with the patient in right lateral decubitus; in case of very acute angle (red dot), it is scarcely modified by the supine position.
To further facilitate the maneuver, the endoscopist asks the nurse assistant to press manually on the umbilical region, to prevent the re-occurrence of parasite loops in the sigmoid (Fig. 8).