Name: Structured Approach to Colonoscopy Technique Optimization: A Single-Center Experience with Novice Endoscopists (Video) | JoVE Journal
Uploaded: 2025-07-11T14:10:00.000+00:00
Duration: 3 min 43 s
Description: Learn structured colonoscopy techniques for early gastrointestinal tumor detection using AI-assisted endoscopy and VR training. This method helps novice endoscopists achieve high success rates with minimal patient discomfort.

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The authors have no acknowledgements.

This study was approved by the Shanghai Civil Aviation Hospital Committee (Ethics Approval No: 2023-02). This work was supported by the Scientific Research Project of Health and Wellness Committee, Changning District, Shanghai (No. 2023QN30), and the Foundation of Shanghai Civil Aviation Hospital Project (No. 2024mhyk001).
NOTE: Figure 1 shows the different regions observed under a colonoscope.
1. Preoperative preparation
<ol>
	<li>Arrange for the patient to consume laxatives to ensure proper bowel preparation.</li>
	<li>Instruct the patient to fast for 8 h before surgery for fluids and 12 h for solid foods.</li>
	<li>Decide whether to administer general anesthesia based on the patient&#39;s condition.</li>
	<li>Consult a senior specialist if experience in performing colonoscopies is insufficient. Review instructional videos and guidelines before attempting a colonoscopy. Seek feedback from experienced colleagues after each attempt. 
	NOTE: Effective bowel preparation and an experienced colonoscopist are crucial for optimal colonoscopy outcomes and accurate problem detection.</li>
</ol>
2. Sedation protocol
<ol>
	<li>Prioritize patient comfort and safety by implementing a stratified sedation approach.</li>
	<li>Administer moderate sedation using midazolam (1-3 mg intravenous [IV]) and fentanyl (50-100 &#181;g IV) for low-risk procedures to achieve effective anxiolysis.</li>
	<li>Use deep sedation with propofol (1-2 mg/kg IV bolus followed by 50-200 &#181;g/kg/min infusion) under an anesthesiologist&#39;s supervision for patients with obesity (BMI &#62; 30).</li>
</ol>
3. Rectum exploration
<ol>
	<li>Minimize the use of air and opt for water instead to reduce discomfort.</li>
	<li>Switch to air insufflation if bowel preparation is inadequate for water exchange/immersion.</li>
	<li>Reschedule the procedure if residual stool obstructs mucosal visualization.</li>
	<li>Rotate the scope carefully when advancing. 
	NOTE: At the initiation of the rectum examination, it&#39;s important to minimize air usage and perform careful rotations. Given that the sigmoid colon often naturally rotates in a clockwise direction, executing a significant leftward rotation at the rectum-sigmoid colon junction facilitates easier subsequent clockwise navigation through the sigmoid colon.</li>
</ol>
4. Sigmid colon exploration
<ol>
	<li>Adjust the tip of the colonoscope so the lens is slightly bent for better navigation.</li>
	<li>At the first turn at the junction between the rectum and sigmoid colon, execute a large-angle counterclockwise rotation, followed by a clockwise rotation through the remainder of the colon.</li>
	<li>Ensure the colonoscope can rotate and move freely without obstruction.</li>
	<li>Detect and reduce any looping of the colonoscope.</li>
	<li>Straighten the sigmoid colon as much as possible.</li>
	<li>Apply clockwise torque to the scope while maintaining minimal air insufflation (&#60;300 mmHg)</li>
	<li>If resistance is encountered, follow the steps 4.7.1-4.7.3.
	<ol>
		<li>Withdraw scope 5-10 cm.</li>
		<li>Apply abdominal pressure at the left lower quadrant using the palm heel technique.</li>
		<li>Reattempt advancement with combined right/left torque alternations. 
		NOTE: Allocate most of the time and patience to managing the sigmoid colon, as it is the segment most prone to looping. Proper management of the sigmoid colon is essential to ensure a smooth and safe colonoscopy.</li>
	</ol>
	</li>
</ol>
5. The descending colon exploration
<ol>
	<li>Rotate clockwise and gently withdraw the body of the colonoscope, simultaneously pulling it out slightly.</li>
	<li>Keep the colonoscope lens steady for improved visualization.</li>
	<li>Rotate counterclockwise to transition into the transverse colon. 
	NOTE: When the colonoscope reaches the descending colon, a clockwise rotation combined with gentle retraction helps minimize loop formation in the sigmoid colon. Without sigmoid loops, navigation through the descending colon is relatively smooth when proceeding counterclockwise. Quick detection of loop formations is crucial when difficulties arise, as the colon is largely mobile5.</li>
</ol>
6. The transverse colon exploration
<ol>
	<li>Advance the colonoscope while gently lifting the lens and inhaling carefully.</li>
	<li>Retract the scope while pressing down on the lens to maintain stability.</li>
	<li>Gently inhale when approaching the hepatic flexure, then rotate clockwise to enter the ascending colon.</li>
	<li>Detect and address any looping of the colonoscope. 
	NOTE: With the prior sections of the colon properly managed, navigating the transverse colon becomes comparatively easier. However, remain vigilant during inhalation at entry and when the lens is lifted, as the suction port is positioned below. In cases of difficulty at turns within the transverse colon, it can be beneficial to inhale air while retracting the colonoscope and stabilizing the lens. Additionally, suitable postural adjustments may offer assistance.</li>
</ol>
7. The ascending colon exploration
<ol>
	<li>Inhale while advancing the colonoscope.</li>
	<li>Continue until the ileocecal valve is out of view, then rotate counterclockwise while keeping the colonoscope tip elevated.</li>
	<li>Monitor and minimize any looping. 
	NOTE: When the colon begins to contract due to reduced air, it is an opportune moment to gently advance the colonoscope.</li>
</ol>
8. The cecum exploration
<ol>
	<li>Observe the ileocecal valve; this serves as a marker for a successful colonoscopy.</li>
	<li>Carefully examine the ileocecal region and appendix opening to avoid missing any lesions. 
	NOTE: In certain conditions, such as specific small intestine diseases and inflammatory bowel disease (IBD), it is advisable to advance approximately 10 cm into the terminal ileum for observation. Be mindful that the ileocecal mucosa is delicate and prone to perforation.</li>
</ol>
9. Postoperative care
<ol>
	<li>Monitor the patient closely for any abdominal symptoms, such as nausea, abdominal pain, or vomiting, following the procedure.</li>
	<li>Allow the patient to consume semi-liquid foods starting 2 h after the operation.</li>
</ol>

<ol><li>Sung, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Global+Cancer+Statistics+2020%3A+GLOBOCAN+Estimates+of+Incidence+and+Mortality+Worldwide+for+36+Cancers+in+185+Countries%5BTitle%5D)+AND+%22CA+Cancer+J+Clin%22%5BJournal%5D)">Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.</a> CA Cancer J Clin. 71 (3), 209-249 (2021).</li>
<li>Zauber, A. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Colonoscopic+polypectomy+and+long-term+prevention+of+colorectal-cancer+deaths%5BTitle%5D)+AND+%22N+Engl+J+Med%22%5BJournal%5D)">Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.</a> N Engl J Med. 366 (8), 687-696 (2012).</li>
<li>Shahini, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Factors+affecting+the+quality+of+bowel+preparation+for+colonoscopy+in+hard-to-prepare+patients%3A+Evidence+from+the+literature%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature.</a> World J Gastroenterol. 29 (11), 168-1707 (2023).</li>
<li>Kawai, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Investigation+of+the+new+advantages+of+colonoscope+insertion+with+an+endoscopic+position+detection+unit%5BTitle%5D)+AND+%22Diagnostics+%28Basel%29%22%5BJournal%5D)">Investigation of the new advantages of colonoscope insertion with an endoscopic position detection unit.</a> Diagnostics (Basel). 12 (11), 2610(2022).</li>
<li>Zagari, R. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Corrigendum%3A+Adherence+to+European+society+of+gastrointestinal+endoscopy+quality+performance+measures+for+upper+and+lower+gastrointestinal+endoscopy%3A+a+nationwide+survey+from+the+Italian+society+of+digestive+endoscopy%5BTitle%5D)+AND+%22Front+Med+%28Lausanne%29%22%5BJournal%5D)">Corrigendum: Adherence to European society of gastrointestinal endoscopy quality performance measures for upper and lower gastrointestinal endoscopy: a nationwide survey from the Italian society of digestive endoscopy.</a> Front Med (Lausanne). 11, 1406746(2024).</li>
<li>Watson, R. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Accessing+a+difficult+colon%5BTitle%5D)+AND+%22Gastroenterol+Hepatol+%28N+Y%29%22%5BJournal%5D)">Accessing a difficult colon.</a> Gastroenterol Hepatol (N Y). 17 (2), 79-81 (2021).</li>
<li>Wei, M. T., Friedland, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Strategies+to+manage+the+difficult+colonoscopy%5BTitle%5D)+AND+%22World+J+Gastrointest+Endosc%22%5BJournal%5D)">Strategies to manage the difficult colonoscopy.</a> World J Gastrointest Endosc. 15 (7), 491-495 (2023).</li>
<li>Rizek, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Rates+of+complete+colonic+evaluation+after+incomplete+colonoscopy+and+their+associated+factors%3A+a+population-based+study%5BTitle%5D)+AND+%22Med+Care%22%5BJournal%5D)">Rates of complete colonic evaluation after incomplete colonoscopy and their associated factors: a population-based study.</a> Med Care. 47 (1), 48-52 (2009).</li>
<li>Rex, D. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((How+I+approach+colonoscopy+in+anatomically+difficult+colons%5BTitle%5D)+AND+%22Am+J+Gastroenterol%22%5BJournal%5D)">How I approach colonoscopy in anatomically difficult colons.</a> Am J Gastroenterol. 115 (2), 151-154 (2020).</li>
<li>Takahashi, Y., Tanaka, H., Kinjo, M., Sakumoto, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prospective+evaluation+of+factors+predicting+difficulty+and+pain+during+sedation-free+colonoscopy%5BTitle%5D)+AND+%22Dis+Colon+Rectum%22%5BJournal%5D)">Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy.</a> Dis Colon Rectum. 48 (6), 1295-1300 (2005).</li>
<li>Moon, S. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Predictors+for+difficult+cecal+insertion+in+colonoscopy%3A+The+impact+of+obesity+indices%5BTitle%5D)+AND+%22World+J+Gastroenterol%22%5BJournal%5D)">Predictors for difficult cecal insertion in colonoscopy: The impact of obesity indices.</a> World J Gastroenterol. 23 (13), 2346-2354 (2017).</li>
<li>Lee, J. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+risk+of+colorectal+cancer+and+related+deaths+after+a+colonoscopy+with+normal+findings%5BTitle%5D)+AND+%22JAMA+Intern+Med%22%5BJournal%5D)">Long-term risk of colorectal cancer and related deaths after a colonoscopy with normal findings.</a> JAMA Intern Med. 179 (2), 153-160 (2019).</li>
<li>Zessner-Spitzenberg, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Impact+of+bowel+preparation+quality+on+colonoscopy+findings+and+colorectal+cancer+deaths+in+a+nationwide+colorectal+cancer+screening+program%5BTitle%5D)+AND+%22Am+J+Gastroenterol%22%5BJournal%5D)">Impact of bowel preparation quality on colonoscopy findings and colorectal cancer deaths in a nationwide colorectal cancer screening program.</a> Am J Gastroenterol. 119 (10), 2036-2044 (2024).</li>
</ol>

The authors have nothing to disclose.

Colonoscopy is a complex procedure that can be influenced by various factors. The technique can vary significantly between procedures, and there is always a risk of colonic perforation12. Colonoscopy varies greatly from procedure to procedure, and there is a risk of perforation and tearing of the colonic belt. Previous studies have identified three anatomical factors contributing to lower success rates in cecal intubation: a lengthy bowel, an angular sigmoid colon, and abdominal wall hernias<sup c...

Cancer, the world&#39;s second leading cause of death, poses a significant threat to people&#39;s lives and health1,2. Colonoscopy is considered the &#34;gold standard&#34; for diagnosing issues in the colon and terminal ileum, such as ulcers, inflammation, polyps, and tumors. Beyond its diagnostic capabilities, colonoscopy also serves a therapeutic role3. This study focuses on enhancing the success rate of colonoscopies performed by beginners, who often struggle to improve their proficiency and efficiently complete the procedure.
A colonoscope is a thin, flexible tube equipped with a camera at the end4. This technique surpasses previous methods by increasing success rates in challenging cases and minimizing patient discomfort. Previous studies have clarified the definition of difficult colonoscopies, distinguishing between cecal intubation time and patient pain5,6,7,8,9,10,11. Factors like a history of abdominal surgery, advanced age, and female sex are associated with increased difficulty.
The methodology of this study emphasizes minimal gas usage and strategic lens rotation as the procedure begins at the rectum. At the first rectal turn, the colonoscope should be applied with clockwise torque, then anticlockwise torque, to navigate the sigmoid colon, carefully guiding it through to the cecum. However, this approach poses challenges when dealing with complex bowel anatomy, requiring greater patience and a higher skill level. Managing air volume and timing during navigation of difficult colonic angles is crucial. Gentle abdominal pressure can assist in advancing the colonoscope.
The key to improving success rates among beginners lies in controlling the amount of air used and properly rotating the colonoscope. By ensuring thorough bowel preparation and exercising precise control over the procedure, colonoscopy can be performed more efficiently, enabling the effective detection of intestinal issues.

<table><tbody><tr><td>Dyclonine Hydrochloride</td><td>Yangzijiang Pharmaceutical Group</td><td>N/A</td><td>0.1 g</td></tr><tr><td>Olympus CF-HQ290L/I Video Colonoscope</td><td>Olympus (China) Co., Ltd.</td><td>CF-HQ290L/I&amp;nbsp;</td><td></td></tr><tr><td>Olympus EVIS LUCERA ELITE CV-290 Video Processor System</td><td>Olympus (China) Co., Ltd.</td><td>CV-290</td><td></td></tr><tr><td>Olympus GIF-HQ290 Video Gastroscope</td><td>Olympus (China) Co., Ltd.</td><td>GIF-HQ290</td><td></td></tr><tr><td>Physiological saline</td><td>Chenxin Pharmaceutical Co., Ltd</td><td>N/A</td><td>100 mL</td></tr><tr><td>Propofol</td><td>Chenxin Pharmaceutical Co., Ltd.</td><td>N/A</td><td>0.2 g</td></tr><tr><td>Simethicone Powder</td><td>Zigong Honghe Pharmacy Co., Ltd.</td><td>N/A</td><td>5 g</td></tr></tbody></table>

structured approach to colonoscopy technique optimization: a single-center experience with novice endoscopists

Structured Approach to Colonoscopy Technique Optimization: A Single-Center Experience with Novice Endoscopists

A colonoscope is a vital instrument used in performing colonoscopies, with the goal of identifying pathology such as ulcers, inflammation, polyps, and tumors. For screening colonoscopies to effectively reduce the incidence of colon cancer, they must be conducted with high precision and quality. However, for beginners with limited experience, achieving a successful colonoscopy can be a significant challenge. Due to a lack of skill, the success rate of reaching the cecum may be lower, and it is often difficult for novices to become proficient in a short period of time.
During colonoscopy, the equipment can stretch the colon, potentially causing local spasms and distension, which may lead to discomfort in patients, including discomfort and pain, issues that can impede the procedure's progress when conducted by less experienced practitioners.
At our center, we have performed tens of thousands of colonoscopies, and currently, about 98% of these procedures successfully reach the cecum. For doctors who are still developing their colonoscopy skills, it is crucial to focus on honing their technique. Therefore, this study aims to analyze and share insights into effective colonoscopy techniques, providing a valuable learning experience for those training in this field. The following section explores critical insights and implementation experiences related to these methodologies.

Over the course of approximately 1 month, we conducted more than 1,600 colonoscopies, including around 1,400 with anesthesia and 200 without. The average patient age was approximately 48.9 years, with the majority being women. We achieved a success rate of about 98.4% in reaching the ileocecal region. The average procedure time was 9 min, and postoperative patient discomfort was reported in less than 5% of cases (Table 1).
<img alt="C...

This study presents an effective approach to performing colonoscopies. Achieving success in this procedure involves ensuring thorough bowel preparation, carefully inserting the scope while minimizing air insufflation, and skillfully managing any looping of the instrument.

A colonoscope is a vital instrument used in performing colonoscopies, with the goal of identifying pathology such as ulcers, inflammation, polyps, and ...

My research focused on helping beginner learn endoscopy, specifically for early detection of gastrointestinal tumors. We use high-definition endoscope AI software to spot tumor and the VR simulators to help a beginner practice. Some challenges include improving early cancer detection, helping beginner learn faster and reducing the chances of missing tumors.[Narrator] To begin rectum exploration, introduce the colonoscope into the rectum of a sedated patient. Minimize the use of air, and instead use water to reduce patient discomfort. Switch to air insufflation if bowel preparation is insufficient for water exchange or immersion. Using gentle motions, rotate the colonoscope while advancing through the rectum. For sigmoid colon exploration, adjust the tip of the colonoscope to slightly bend the lens for better navigation through the sigmoid colon. At the first turn at the junction between the rectum and sigmoid colon, rotate counterclockwise at a large angle, then proceed with a clockwise rotation along the rest of the segment. Ensure that the colonoscope rotates and moves freely without resistance. Identify and reduce any looping of the scope as needed. Next, explore the descending

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Learn structured colonoscopy techniques for early gastrointestinal tumor detection using AI-assisted endoscopy and VR training. This method helps novice endoscopists achieve high success rates with minimal patient discomfort.

Structured Approach to Colonoscopy Technique Optimization: A Single-Center Experience with Novice Endoscopists

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