Okay, welcome back, our virtual audience. This is the virtual Bioskills Lab session, and this will consist of a series of endoscopic videos and instruction that was recorded by my colleague, Dr. Keith Opstein, who is at Vanderbilt University. There'll be six total videos that we have the opportunity to view, and at the end, I will open it up for questions and add some comments to Dr. Opstein's instructions. The first video is entitled Basic Scope Handling, and it is really an overview of how gastrointestinal endoscopes work. So without further ado, we'll go ahead and start that video. Hello everyone. My name is Keith Opstein, and I'm an Associate Professor of Medicine and Mechanical Engineering at Vanderbilt University. I'm also an active member of the ASGE and proud to be here today to be doing this video for you. Today we're going to be talking about basic scope handling. All endoscopes, no matter the manufacturer, have the same principles. Essentially, there's a series of knobs on a handle, buttons that control both insufflation, irrigation or lens cleaning, and suction, and the wheels articulate the tip. They're all connected to a series of either light source or processor that can either turn on or off the light, on or off insufflation, and have your connections for suction. What I'll do now is show you the basic technique. Essentially, if you place your hand in a V formation, and the endoscope simply is placed into your hand as follows. That way, as you can see, it won't rotate out of your hand, so you won't lose your grip, and you can place your fingers around so that you can essentially have one hand over the top button and one hand over the lower button. We can see that when you turn the wheel, as I rotate the large wheel back, you can see the tip of the endoscope move. When I rotate it forward, you can see it articulate down. When we come to the center, the smaller wheels can then move it away or deflect it in the opposite direction. A unique thing about endoscopes is that seeing that it's a long insertion tube, you can simply rotate your wrist to get complete 360 degree motion. What I'll do now is I'll turn on the light, and so you can see illumination or the light source. It's very bright, but it can auto-correct on a lot of the current machines and processors. We have air as well, which can be turned on or off, and then certain other features can be used for advanced imaging. We have two separate buttons. One of them, the top one, is for suction. By depressing it down or pushing it, you can get good suction. The bottom button is dual function. There's a hole in the center. When you simply place your finger over the hole, you can hear air come out the tip of the endoscope. That is so that the colon or the stomach or whichever gastrointestinal organ you're in insufflates. When you simply remove your finger from that hole, this air insufflation will stop. What's happening is it's actually exhausting into the environment and not going down the endoscope for insufflation. Using that same button, if you push it down all the way, you'll see you'll get lens cleaning and water will come out the tip. That cleans stool or mucus off the tip of the endoscope. Simply letting that go will stop that function. A variety of endoscopes by multiple manufacturers also have a series of buttons. These buttons can be programmed to have different functions, including changes of light to different wavelengths, capturing of photos or videos, or whatever else the physician or endoscopy team would like to program those buttons to do. You'll also notice that there's two larger wheels here that tend to click. These are called wheel locks and can lock the wheels in a certain position. These are less commonly used in standard practice, however there are some cases and different functions for which they are useful. When we do basic endoscopy, we try to take the wheel locks off so that you can have full articulation of the tip in whichever direction you want to go and not be impeded. We see here the bottom portion. This here is a cap and caps can come off. Simply the cap maintains your ability to put in water or air and not have it be exhausted back out. When you use something like a biopsy forceps, a needle, a polypectomy loop, they go through here, also known as the therapeutic channel. By passing an instrument through this port, it will come out the end of the endoscope for your use and we'll see that in some of the later videos. All the buttons are also removable and so you can simply pop them out and pop them back in. Just make sure that they're seated properly when you do and you'll have return of your function. The principles of the upper endoscope are essentially the same when we use a colonoscope, which we have here. The colonoscope has the same principle and function, meaning it has the two sets of wheels with Bowden wires that control or articulate the tip. You have your same functionality, suction, insufflation, depression of the bottom button for irrigation or lens cleaning. You can see the difference between the two endoscopes in that one is thinner diameter, that's the upper endoscope, and one is thicker and that's the colonoscope. They also have different lengths. If I lay them out, you can see that traditionally the colonoscope is a much longer endoscope. That's solely by nature of design as well as human anatomy to get around the colon to get to the cecum and into the terminal ilium. Certainly there's different lengths of both pieces of equipment and different diameters depending on if you're using therapeutic dedicated endoscopes or if you have shorter colonoscopes. But the principles overall of basic scope technique are the same. Again, when you handle the endoscope, I like to make a V with my hand and drop the endoscope in so that I can control the tip deflection with one hand while I'm using the insertion tube to advance. I'll demonstrate this now on the stomach model. So one of the things that I'm doing is I'm rotating the endoscope to make sure that I don't have any loops in the back tubing that go into the light source and processor. We'll take our endoscope here, holding it as we discussed, and then we'll insert. We need to use lubrication involved. I have this endoscope lubricated and we'll go down the esophagus now and I'm watching the monitor. I'm trying to keep my body square and you'll see how we can use insufflation to come into the stomach and lens cleaning to clean off the mucus that was there. We're in the stomach now and so what we'll do is I'll insufflate and you'll see the lumen expand and we're in the stomach model and you can see insufflation here very nicely. When I articulate the tip with my hand, you'll see the endoscope can look up, we can look down or simply by rotating my body and my hand, I can rotate the plane that the endoscope is in. Again, if I want to use suction, I can suction down the mucosa or if I clean my lens, you can see water come over the lens to do that. Thank you for your attention. I just wanted to add a few comments about the basic scope design and handling. Interestingly, the overall design of endoscopes really hasn't changed much in roughly 30 to 40 years. There are some slight changes in the way that the images are processed and the fidelity or the resolution of the images has clearly improved quite a bit. The efficiency and the size of the endoscopes have also changed slightly over time. But the functionality and the therapies and the assessments that we can perform with gastrointestinal endoscopes really remains fundamentally based on what we can see visually. Dr. Opstein did cover the fact that there are a number of devices that we can pass through both the upper endoscope and the colonoscope in order to perform therapies, acquire tissue samples, and we'll get a chance to see some of those devices in action with some of our other videos. He also pointed out that the upper endoscope and the colonoscope are really very similar in functionality but have differences in the diameter and the length of the scopes. Some of the channel sizes also are different in those upper versus colonoscopes. What you noticed Dr. Opstein doing when he was manipulating the endoscopes, it was almost like playing a musical instrument in order to coordinate the action between depression of the buttons or covering the buttons or manipulation of the dials, the up, down, and left, right dial. All of that is really take some coordination and take some familiarity with these devices. And so that's why it takes years to really perfect the skill of gastrointestinal endoscopy. We now have simulators, electronic simulators, and also ex vivo simulation models which our other in-person participants are currently working on in our bio skills lab. And those simulation sessions really give endoscopists, especially endoscopists that are learning, our trainees, the ability to acquire these skills, acquire that familiarity with the endoscopes outside and within the safety of not doing it in live patients.

virtual Bioskills Lab session

Dr. Keith Opstein

endoscopic videos

gastrointestinal endoscopes

scope handling