IntroductionOvert obscure gastrointestinal bleeding (OGIB) is challenging and often needs intraoperative endoscopy (IOE) with a high risk of morbidity and mortality. The study was to compare the different approaches to perform IOE for overt OGIB. Patients and methodsWe retrospectively reviewed the data of 98 patients who underwent trans-enterotomy IOE (IOE-E) or other approaches such as peroral IOE (IOE-oral), trans-anal IOE (IOE-anal), or combined route (IOE-combo). Patient characteristics, demographics, diagnostic tests, IOE findings, and follow-up outcomes were analyzed. ResultsAll 98 patients underwent IOE. There are 31 patients in the IOE-E group, 26 patients in the IOE-oral group, 23 patients in the IOE-anal group, and 18 patients in the IOE-combo group, respectively. Long-term follow-up information (>6 months) was successfully obtained in 72 patients. IOE-E has the lowest postoperative morbidity rate (16%, P < 0.05), the shortest time of operation (43.2 ± 17.4 min, P < 0.05) and shortest hospital length of stay (6.7 ± 5.1 days, P < 0.05), as compared to the other three approaches. ConclusionsIntraoperative endoscopy through enterotomy represents a safer and more ideal strategy in the management of overt OGIB.