Emmanuel Coronel, MD and colleagues from the Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, at the University of Chicago in Chicago, Illinois, USA share this video case “The ‘Moonsault’ maneuver: retroflexed ileocecal valve insertion.”

In this video we describe a different technique to achieve ileal intubation. We reach the cecum using a pediatric colonoscope (PCF-H190L/I, Olympus, America, Inc.). Once in the cecum, we attempt a retroflexion by simultaneously applying a maximum up-angle with a gentle advancement of the scope. The valve then can be seen at 6 o’clock position, the colonoscope is pulled back, and by using this maneuver the scope falls into the ileocecal valve allowing for insertion. The dials are then returned to a neutral position and we are able to push forward and continue the exam of the ileum.

Figure 1. A, A pediatric colonoscope is used to reach the cecum. B, Once the cecum has been reached, we attempt a retroflexion by simultaneously applying a maximum up-angle with gentle advancement of the colonoscope. The valve then can be seen at the 6 o’clock position. C, The colonoscope is pulled back, and by use of this maneuver the colonoscope falls into the ileocecal valve, allowing for insertion.

A different approach in intubating the terminal ileum can be useful when a standard intubation becomes difficult. Intubation of the terminal ileum is an important part of colonoscopy. It is often performed in patients with inflammatory bowel disease to document involvement in the terminal ileum or for completeness of an exam in the right clinical setting, such as in patients who present with right lower quadrant abdominal pain or diarrhea. In addition, intubation of the terminal ileum has its own learning curve and the position, shape and anatomy of the ileocecal valve can be variable, thus posing challenges to a gastroenterologist.

From our experience this is a safe and effective technique to achieve ileal intubation. Many studies have shown that cecal retroflexion is safe and does not lead to increased rates of colonic perforation. A few technical tips we noticed are that having a straight colonoscope is key in performing this maneuver. It can be performed with an adult or pediatric colonoscope and there is no restriction in patient position.

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