Technique for fine adjustment of snare size during endoscopic mucosal resection by a single endoscopist

Performing endoscopic mucosal resection for polyps located in the hepatic flexure is always challenging. The two most important reasons that make removing polyps in the hepatic flexure difficult are the instability of the position of the endoscope and the difficulty in advancing the endoscope’s accessories while in that bent angle. To overcome the instability of the endoscopic position, the left pinkie maneuver can be applied [1]. The cases shown here demonstrate that an “open-and-retract maneuver of the snare” could solve the approach problem ([Video 1]).

Video 1 Open-and-retract maneuver of the snare: a solution in cases where it is difficult to approach a polyp in the hepatic flexure with the snare.

As shown in the video, a fully opened snare cannot approach the polyp owing to the angle of the hepatic flexure and the mucosal folds that are covering the polyp. To solve this problem, the open-and-retract maneuver of the snare can be applied. After the snare is fully opened, it is retracted into the hole of the working channel, and the fully opened snare is slowly released while the mucosal folds covering the polyp are retracted with the clear cap. All of these procedures must be performed concurrently with the left pinkie maneuver to allow for a single endoscopist to operate [1]. This technique allows for fine adjustment of snare size during endoscopic mucosal resection by a single endoscopist.

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• Reference

• 1 Uno Y. The left pinkie maneuver of the colonoscopy. Gastrointest Endosc 2009; 69: 191-192