So, for the next demonstration, we're going to do a lesion in retroflexion, so let's see if this model will allow this scope to kind of retroflex here towards the end. If not, we can always switch out to another, to an upper scope. Okay, so we are able to, oh, so this is actually a good one here. Because the challenge for these type of lesions that when it's close to the retroflex scope is how you really work in this kind of backwards orientation. So this is like driving down the highway in reverse, right? So, you know, when you push in, instead of getting closer, you actually get further away. When you pull your scope towards you, you actually get closer to the lesion, and then, you know, similar to your right and left, everything's kind of, you know, backwards. So this is a good lesion. So tell me about your injection kind of strategy for something like this. So I think I'll use the same strategy where this time, instead of injecting, you know, at the proximal end, I'm going to start injecting on the distal end so that the bulge, you know, the polyp, the lesion comes towards me. The polyp comes close to you, yeah. And then we can, you know, use the same strategy a little bit on the left and the right side and see how it goes. Exactly. Okay. All right. So let's go ahead right here. Here you go. Thank you very much. All right, needle out, please. All right, needle out. So the challenge for these is that sometimes you don't get that same sort of deflection, because not only are you in retroflex, but the needle is in this kind of upwards trajectory. So we're going to see if we can kind of just kind of reorient the scope, and then through a series of maneuvers kind of angle the needle tip down. That looks a little bit better there. The other option, of course, is to, you know, inject in the center of the polyp as well. Sure. But I think here, you know, we have a decent fold. Yeah, needle back just for a second, please. Okay. I'm just going to use the catheter tip as a stick to... Okay, so he's going to actually use the catheter to kind of move this around, and maybe move the folds around a little bit. This is where the cap is also helpful. Yeah, maybe here we can try. Okay, yep, so he's kind of got this spot right here. So needle is out. Okay. Okay, he's going to jab it and then pull it back. Okay. One more time. Okay, go ahead. Okay. Yep, just pull. Slide injecting, please. Okay. No. Okay. All right, so nice lift here. So we can see the polyp is actually coming back towards our scope. So dynamic injection. So if we want to do dynamic injection, do we go towards the lumen? Really, it's wherever your lift is insufficient. So here on the right side, it's a little weaker than the other areas. So he's going to turn his little wheel to the right. And now we should start seeing this side. Yep, there it is. So now this side is lifting up well. So it's really when you're looking at your overall lift, which direction would you prefer that you get more lift? So here is on the right side. So let's pull our needle back. Okay. And pull the scope back. And so now this polyp actually has come back towards us, you know. I'll just do my. Let's do the retroflexion. Yeah, I'm going to use the needle again. So. So one of the important features in right colon retroflexion is that it's not the same as rectal retroflexion, where you're really just jamming the scope in and it forces itself to kind of. Here what I often do is I'll turn my little wheel either to the right or left first. I'll lock it and then I'll push the scope in gently while mostly torquing the scope. All right. So needle is out here. So maybe a little bit in the center of the. Yeah, I think so too. So it's kind of got that back edge pretty well. Yeah. Okay, so we've jabbed there. Yeah, let's start injecting please. We just switch Okay. Oops. All right. Just give it a jab. All right. There we go. Now we're getting a good lift. It's the same thing here. Our injection onto the right is maybe not as strong. So just readjusted there. Now okay. All right. How do you feel about that lift? I think it looks pretty good. Pretty good, right? Yeah. Kneel to the back, please. Yep. Kneel up. Okay. Yeah. I can actually get away from the polyp here. Yeah. So that looks pretty good. Yeah. Excellent. Okay. All right. Let's go ahead and switch to our snare. So question, Dr. Raman. Yeah. Do you just, you know, in this position, just keep your small wheel locked and... I do. In retroflexion, I find it'll maintain the retroflexion a little bit easier as well. So the little wheel is locked here. Yep. Okay. All right. I think that other snare would probably be a pretty good option for this one as well. Sure. Thank you. Thank you. Thanks. So I think our true, you know, lesion is this front, I mean, this proximal bump. Yep. That's our injection from before. Yeah. All right. So here, you know, in order to keep everything parallel, it's got to adjust the scope as well as the wheels. Okay. And this is where it becomes a little bit challenging because, you know, this now this snare comes out a little bit funny. So it's really a lot of manipulation with the dials. And then the correction is, you know, with the scope. So he'll do kind of a right direction torque in a clockwise orientation to, and then he's applying the big wheel away from him. And it just depends on how well it's all going to work in retroflexion. So he's just going to have to maneuver the scope in the different ways to get that to happen. Okay. And pull his scope towards him. Yep. Like that. That's great. So that's a good initial. Yeah. Yep. Okay. So that's a good grab. There's no slip. So that's good. Okay. So on three, one, two, three. Okay. Okay. Went through. Okay. So that went through pretty easy. So now that should give him a good anchor point for his next. Yeah. Maybe, do you use your pinky technique in the retroflex if you need to? I'm sorry? Do you sometimes use your like this pinky technique in the retroflex? Yeah. Yeah. You certainly can. Yep. I think like I need some stability here for my scope. Okay. All right. Is this open all the way, Dr. Adhan? Yeah. So the problem here is that the snare is not totally cooperating. So we'll see if we can maybe adjust for it, but otherwise we may have to switch to a different type of snare. But overall, he's kind of working the way he wants. Can you start closing, please? Okay. Let's see if this works here. So he got a little bit of tissue. It's actually not too bad. Okay. Go ahead. Okay. Went through. Okay. So this is good. He's overlapping very nicely. Start closing. Okay. You're going to start closing. He's doing a good job pushing forward. Okay. Go ahead there. So that situation, you know, the catheter got a little bit away from the colonoscope, but I think that was necessary in order to keep the snare from slipping off that polyp too much. Right. Okay. So, so far, no bridges in between. This overall is looking pretty well. Okay, we're going to come back, and start closing, and it's too small of a piece. But overall it's coming along pretty well. So maybe I can focus on this bigger piece for now, and then come back to that. So the question was, you know, how to decide when to deflect right or left. There's really no right answer, you know, sometimes it's just what feels more comfortable, and sometimes you would have to try out both directions. Yep, start closing please. Okay, go ahead. Good. Okay. Good. So, really kind of using the way that the snare is working out for him to his advantage there. Okay. Okay. Thank you. Do you think this is good enough or is it too much? So there's a little bit of tissue that was in between, I think that resection right there got that. Yeah. Okay, great. So now, so this is the whole point, you know, you want to make these easier for you. So he worked from one direction, you know, went to the right, now kind of working his way back towards the left, and now the snare is actually cooperating as well. So I think we're just left with this distal portion here. Yeah. So that one should come in, you know, relatively well with the snare. Right. Let's start closing, please. start closing slowly. Okay. All right. All right. Yep. That's great. Okay. So there's a question on how do we get our nurses to inject? Do you tap it? Do you give it the same kind of speed throughout? So generally, you know, you'll start a little bit. You want to make sure you don't want to give it, of course, like all five cc's at one time. So you'll start and you want to make sure that you're in the same plane. So it's a little bit, you know, maybe a half ml as long as you're in the right space. Then it's kind of a continuous injection, you know, until you have your desired lift. All right. So that turns a little wheel to the left here a little bit. And then this is becoming a little bit tricky here. All right. So let's wash these off here. Okay. Good. So now inspecting the lesion. Yeah. Overall looks pretty good. Overall looks pretty good. I think maybe maybe that right there. Yep. So make sure there's no residual there. Start closing please. Yep. Okay. Maybe this, maybe that, yep I would get that. Okay, yeah. So there's a lot of things happening here at the same time. He's adjusting his scope, he's adjusting his wheels, right since we're in retroflex he's going big wheel away to to deflect that snare in that downward direction. Okay, I think that's pretty good. I think that was just kind of a snare pulling off there, yeah. Yeah. So let's take a look. So he's pushing his scope in to kind of take to get a better look there. So overall, overall this looks pretty good. Let's look at the anti-grade direction. Okay. Because you always want to make sure that's not just one view. Right. That you're getting your assessment especially if you're doing it in the retroflex position. So this looks actually really good. So you know that margin looks really clean and you know putting clips on for example in the retroflex position is pretty difficult because this is a really tight angulation. But for here like you could easily do this you know in the anti-grade position. So why don't we throw a couple of clips on there. Sure. You know to show exactly how we would do this. So what do you like to do? Do you think that you would go in the middle and then work towards the sides or go from one side sequentially to the other? Yeah, I think you know it depends on the lesion factors. You know the size, the location, the scope stability and so forth. So if I am in a stable position, you know the lesion is at six o'clock, my scope is stable, I can start from one end to the other or vice versa. That's what I think the preferred way to go is again you know you want to do everything systematically. Right. But if I feel like I'm in a tough spot, the scope is unstable, I might like apply one clip just to get started. Right. Yep. All right. So you know there's a lot of rotatable clips now on the market and this one in particular. There's really two main ways that you can rotate. Okay. So we're going to go ahead and we're just going to demonstrate how that works. So for example here you have this little orange piece. So can we show? Okay. So I'm rotating on this orange piece here and as I'm doing that you can look on the screen here and you should get really a one-to-one kind of rotation. So I'm going clockwise and I'm getting a clockwise turn here. Now the other thing is is let's say you know Dr. Saeed here doesn't trust me or he prefers to do it because it's a very fine movement. He can do it himself at the biopsy channel. So he can just rotate. Yep. Oh yeah. So he can rotate the clip himself. Wow. Because you know let's say I'm doing it and he doesn't want to tell me to oh just a little bit more to the right a little bit. He can do that himself and that way he has really precise control over the clip. Yeah that's so nice. We usually use the cook. Yep. And I think they perhaps are not rotatable from here. Yeah so it depends on the manufacturer. Some you can rotate from the biopsy channel. Some you have to do it from the handle. So just be aware kind of what scopes you have available. What clips you have available sorry and exactly how you would how that works. So here yeah he's doing it himself. So he's going to work on that kind of left side. So so you know it's always important to drive the scope forward instead of setting that clip really far out. Right. You know this really goes back to our you know kind of main principles of working very close to the scope. But here you know. So he's arcing. So he's like he's advancing the scope but it's not it's not getting kind of that six o'clock orientation. So the other thing you do is he could he can suction down. He could either send the clip out or he can work on the right side since it's closer to him. Right. So maybe he's gonna like just change his strategy a little bit and work towards the right and then the subsequent clips should be a little bit easier to place. So so here's fine to go go forward there and then maybe give it a little bit of more of a rotation. So we'll turn it just a little bit towards the right. Let's open back up and right there. Okay. Yeah. So now we're gonna close. Okay. He always pulled back on the clip to make sure that yeah that looks like we got both sides there. Yeah. So we're gonna go ahead and we're going to close and fire the clip. Okay. It looks pretty good. Yeah. So it looks like we certainly got that started. Right. So so the lesion you know my default was like in 12 o'clock position. So I brought it to six o'clock but then I was getting some like you know paradoxic movement. That's how I was having some trouble. So in a scenario like this you sometimes attempt to do it like in a retroflex. Yeah. So that's another option. It's really you want to get everything in the position that's most amenable. Sure. To achieving the outcome that you need. So you know if you have to do it you know in a retroflex position or you know torque the scope you know it's any of those or a combination of things as well. Yeah. Let's put one more clip in and then it's we're going to transition to our next technique. So if I want to try to attempt in a retroflex position I think I should first pass the clip and then yeah get to the tip of the. Yep. So let's let's go ahead and try that. So what he's saying is that if you're very angulated it's difficult to pass these accessories through when you're retroflexed. So what he's going to do here is he's going to get the clip just at the tip of the of the scope and then he's going to do his retroflexion maneuver. It'll be a lot easier to get the the clip out of the scope when it's already at the tip. All right. So there's our our lesions. He's kind of working his way back. Okay. So open please and maybe I can. So there's options he can rotate so we can go you know maybe in a clock counterclockwise. Yeah or maybe like yeah like one. Yep like that maybe and then see if you can lay it down there. All right. Push forward there. Yeah. We'll get a little bit more like that. Yeah. Yep. Now you can push forward with the catheter and suction down a little bit. Okay. Yeah. All right. Close. Close. All right. We're gonna fire that. Okay. All right. All right. I think that looks good. Okay. Overall that looks pretty good. So stay tuned. Just give us about three four minutes. We're going to just turn a few things over and then we're going to demonstrate our next technique. Sure.

doctor

lesion

retroflexion

injection strategy

catheter

snare