Proctoscopy.pdf

Proctosigmoidoscopy: Its Technique

Marie Ortmayer

CA Cancer J Clin

1951;1;189-194

DOI: 10.3322/canjclin.1.6.189

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ISSN: 0007-9235. Online ISSN: 1542-4863.

Proctosigmoidoscopy:

Its Technique

Marie Orimayer, M.D.

Anyone planning to learn this endo

scopic procedure should read the out

standing anatomical, technical, and

procedural descriptions of Bacon,'

Bockus,2 and Buie.3 The advice of the

last on the psychological

handling of

oilâ€”enema technique (a modification of

Weber's preparation for barium enema)

delivers the highest numbers of well

cleansed colons.5 Remembering only

that castor oil is contraindicated in

marked obstruction of the bowel and

in some diarrheas, the instructions

shouldbeasfollows:

1. Take 2 oz. castor oil at 2 P. M. the

day before the appointment.

2. Take a 2 qt. warm-water enema the

morning of the appointment.

3. After the castor oil, take only the

following foods (eat frequently and as

often as you wish and are hungry): Water,

milk, tea, or coffee, with or without sugar

and cream. Strained fruit juices. Strained

soups, ginger ale, or other drinks. Plain or

salted soda crackers, butter, oleomarga

rine. Plain jellies without seeds or skins.

Plain ice cream, plain candies. No nuts.

4. Report at [hour] on Date

anestheticâ€ as he

calls it, is a classic. Many men have de

veloped instruments of varying lengths

and diameters, tables of different types,

all designed with the objective of great

est usefulness and practicability for the

examiner and comfort to the patient.

The Granville Hanes â€œ¿invertedposi

tion,â€ that led Dr. Hanes to design the

first proctoscopic table, developed out

of the amazing reaction of one of his

patients, who had a sore anal canal.

When the physician inserted his finger,

the kneeling patient threw himself vio

lently forward sliding off the opposite

end of the table, with thighs remaining

outstretched thereon and head landing

on the arms on the floor! The doctor

calmed his patient and completed the

examination

easily in this excellent

Whether special tables, adapted ta

bles, beds, or knee-chest positions are

used, routine proctosigmoidoscopy de

mands (1) a well-cleansed lower bowel

and (2) a position of the patient in

which the abdomen is not pressed upon

by thighs or table, and in which the pa

tient can remain co-operative and fairly

relaxed. It is also essential that the oper

ator be relaxed and in balance on two

feet, so that none of his weight rests

heavily on the patient either through

his hands or his body.

The patient should first be placed in

the Sims position for thorough visual

examination of the penianal and anal

regions. One should ask the patient to

bear down, while gently stretching

apart the penianal skin, because the

anal-canal structures frequently come

into full view by this maneuver. Then

follows the rectal digital examination.

Women and Children's Hospital, Chicago, illi

nois.

position.

In this day of making the â€œ¿doctor's

office a cancer detection center,â€ it be

comes essential to train oncoming

physicians in the routine use of procto

sigmoidoscopy. The following direc

tions, which combine the teachings of

the great experts and some manipula

tions and instructions of our own ex

perience, may be useful.

Preparation of Patient for

Proctosigmoidoscopy

Although a thorough enema taken

three hours or more before proctoscopy

by the fasting patient may be sufficient

to clear the bowel of feces and excess

fluids, we have found that the castor

189

the patient, the â€œ¿vocal

Figure 1. The manner in

which the proctosigmoido

scope is grasped by the right

hand before insertion through

the canal.

Figure 2. The manner in

which the left hand supports

the proctoscope and controls

its advance and withdrawal.

Figure 3. This indicates the

revolving pendulum type of

motion imparted to the proc

toscope in order to view the

total â€œ¿clocdialâ€ at various

levels of the bowel when only

sections of the circumference

at a time can be seen through

the proctoscope. The nar

rower the diameter of the in

strument, the more frequently

will this maneuver need ap

plication.

190

Figure 4. Sims Position,

Right- or Left-Lying. The ex

aminer stands at the patient's

back near the patient's but

tocks and does not obscure

the light with his hands or

head. The light should fall

full on the anal region from

somewhere near the foot-end

of the patient.

Figure 5. Knee-Chest Posi

tion. Note that the patient is

placed toward the end of the

table, the feet and ankles ex

tending well beyond it. The

knees are quite wide apart,

the thighs are at right angles

to the table top, and the back

is slightly lordotic. This posi

tion is also used in digital

examination.

Figure 6. Lithotomy Position.

The lithotomy position is used

in digital examination, for

some tumors will fall within

reach of the finger only in this

position.

191

The examiner will carefully palpate

thecompletecircumferencoftheam

pulla, from the lowest to the highest

levels within reach of the finger. There

by he may detect lesions that can be

missed by the proctoscope, particular

ly those in the posterior hollow of the

ampulla just above the anal canal. He

will also palpate the gross ampullar

strictures and tumors before encoun

tering them with the proctoscope. At

this digital examination, the exact di

rection of the anal canal in each indi

vidual patient is determined, so that the

insertion of the instrument is accurate

and easy. It cannot be stated too often

that the proctosigmoidoscopist must

exert every art to avoid giving the pa

tient discomfort. This precept is even

more important for the routine en

doscopy than for the indicated one, be

cause the patient seeking relief from

symptoms is more ready to bear pain

than the asymptomatic individual.

Beginners should not attempt to

proctoscope with the patient in the Sims

position. If the knee-chest position is

used, the patient must have a tripod

base: the knees apart, the thighs at right

angles to the table, and the shoulders

(one or both) down on the table. The

arms can be dropped over the side of

the table or may â€œ¿hugâ€

rel near the eye-end, which usually

carries a flange, between the second and

third fingers of the RIGHT hand placing

the thumb firmly on the plunger, thus

maintaining its position in the barrel

(Fig. 1), so that when the instrument is

inserted into the anal canal the plunger

will not be dislocated from the barrel.

Use a steady pressure in the exact di

rection of the canal and not a screw

motion for the latter may twist the

canal and hurt. The plunger is built to

give a gradually dilating, smooth, non

traumatic insertion of the scope. Usual

ly the give of the anal-canal muscles is

felt as the tip enters the ampulla. The

anal canal is about 3 cm. long but

varies considerably especially in wom

en.

the table and

thus prevent sliding forward. It is usual

ly best to have the patient turn the head

resting the face on a cheek (a small pil

low is useful). Elderly or very stiff

necked patients, however, prefer to rest

the head straight down on the fore

head. Embarrassment of the patient is

minimized by draping that leaves only

the gluteal folds and anal region bare.

All instruments, cotton swabs, electric

current attachments, etc., should be

ready and in place before the patient is

put into position, to prevent undue pa

tient fatigue.

Step 2. The thumb and index finger

of the LEFT hand now firmly grasp the

barrel of the scope close to the patient's

external anal ring (Fig. 2), while the

left fifth finger rests steadily on the pa

tient's left buttock, so that the instru

ment can neither be pulled out nor

pushed in while the right hand removes

the plunger. The light is immediately at

tached, because from now on there

should be no advance of the scope ex

cept under direct vision. The moment

the operator looks through the instru

ment, a blank wall is seen, which is the

ANTERIOR wall of the rectum.

Step 3. Without advancing the scope,

the RIGHT hand guides the eye-end

downwards (toward the floor) so that

the operator may see the lumen of the

ampulla, which lies in the direction of

the sacral hollow.4 It is very rare to find

the rectum collapsed because, with the

patient in the inverted position, air

usually rushes into the ampulla and bal

loons it out the moment the plunger is

removed. This occurs because of the

negative pressure created in the abdo

men at each expiration and is sometimes

well observed higher in the bowel, ow

ing 4o the alternating collapse and sepa

ration of the walls during breathing. If

the walls remain apposed in spite of or

dinary breathing, wetting them with a

sponge dampened

Technique

Step 1. After lubricating the anal

canal, or the instrument, well with a

water-soluble substance, grasp the bar

with WARM water

192

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