You have 7 options. The first four (PDJT) are used routinely. The last three (PPF) are reserved for when the first four fail.
Counterintuitive but extremely effective. Pulling back can straighten the path, reduce looping, and give you a clearer view of where you actually are and where you need to go.
Be mindful of insufflation. Overinflation can make it harder to navigate folds and curves—and increases patient discomfort. Deflating can allow the colon to collapse around the scope and open the path forward.
Small jiggling motions can help tissue move over the scope and allow air or fluid to open folds. This can reveal the lumen and help you progress through tight or angulated segments.
Torque should be applied with the tip bent (thumb up or down) to open folds and navigate corners. Pulling back with torque helps reduce loops; gentle forward pressure with torque can help pass the splenic or hepatic flexure. Sometimes a slight pullback with torque is needed to expose the lumen.
External abdominal pressure can reduce loops and prevent the scope from bowing—especially in thin patients. This often allows smoother advancement.
Typically a last resort when PDJT and pressure fail. Changing the patient’s position (supine, right lateral, left lateral, or prone) can dramatically alter colon geometry and open the path.
Another last-resort technique. Flooding the lumen with water can help with redundant sigmoid colons or challenging anatomy. It requires a large volume of water and often results in a messy cleanup—but can be highly effective.