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During scope advancement, there is a need to provide some inflation of the lumen to allow visibility and identification of lumen and these anatomical clues. However, too much air can actually make advancement around some segments of the colon more difficult to navigate as well as add to the patient discomfort. This is of particular concern when fellows early in training take a long time to pass the sigmoid colon and use excessive air in the process. This can lead to marked distention of the cecum and right colon. The use of water to fill the sigmoid colon (immersion or water exchange technique) is felt by many to make scope advancement through the sigmoid easier for trainees and more comfortable for the patient. While not necessary for more experienced endoscopists during every case, this technique is one more tool to assist navigation through a difficult sigmoid colon.

Figure 6.16 Lumen identification. When the lumen cannot be readily identified, clues such as (A) the arcs of the colon folds, small arcs of reflected light off of the ripples of muscular rings (B), or the area of shadow behind a bright fold (C) can help. Following the indentation of the tinea coli (D) can also guide the endoscopist around acute angulations.