
 colonic perforation is the most serious complication of colonoscopy , with an incidence of 0.35% to 3% during therapeutic endoscopy .
treatment of iatrogenic colon perforation using laparoscopic methods is a novel approach , would result in equal therapeutic efficacy , less perioperative morbidity , smaller incisions and decreased length of hospital stay , and an overall better short - term outcome compared to open methods . 
 
 in this report
, we describe successful laparoscopic closure of a large perforation of the sigmoid colon sustained during a screening colonoscopy . 


 a 66 year - old woman who sustained a colonic perforation during colonoscopy was treated successfully by laparoscopic repair .
she underwent an outpatient screening colonoscopy due to a positive fecal occult blood test . according to the endoscopic report
, the colonoscopy preparation was excellent , with small amounts of clear fluid in the colon .
a large perforation of the sigmoid colon resulted during maneuvering of the endoscope through a sharply angulated sigmoid colon .
1 ) . 
  a large perforation of the sigmoid colon in mesocolic side induced by the colonoscope . 
 during the colonoscope withdrawal ,
( b , c ) abdominal x - rays , demonstrating the air in the retroperitoneum(supine & up - right ) . 

after appropriate laparoscopic mobilization of the affected portion of the colon , the perforation site was located and inspected .
the insufflated mesosigmoid over the laceration was opened and a 2 cm colon perforation was recognized.(fig .
3 ) we performed a two - layer closure , beginning with a running 3 - 0 absorbable suture .
next , an outer layer of interrupted seromuscular 3 - 0 silk sutures was placed using an intracorporeal laparoscopic knot technique .
the perforation was closed successfully with laparoscopic intracorporial suturing . 
  a colon perforation in mesocolic side . 
 then , the proximal bowel was cross - clamped and air insufflated into the rectum with the repair underwater to ensure the absence of any leak . 
 

she was treated with intravenous fluids and antibiotics . except for slight abdominal pain during the first 24 h
the initial white blood cell count was 14,200/mm ( normal 4,60010,500/mm ) and declined to 10,200/mm after 48 h. abdominal pain resolved by day two , her oral feeding was resumed by day three and she was discharged from the hospital by day five . 


 since the introduction of flexible fiber - optic colonoscopy at the beth israel medical center by wolff and shinya in june of 1969 , there have been numerous reports on the safety , cost - effectiveness , and low morbidity and mortality rates of diagnostic and therapeutic colonoscopy .
even though colonoscopy has become progressively more refined , it is an invasive procedure with major complications , such as haemorrhage and perforation .
perforation is a significant and well - recognized , although rare   complication of fiber - optic colonoscopy .
its frequency is estimated to be between 0.35%   to 3% during therapeutic endoscopy , in various published literature .
this wide variation in the incidence of perforation is best explained , most probably , by the expertise of the individual endoscopist and by how meticulously medical centers search for and report postcolonoscopy perforations . 
 

however , it has to be mentioned that there may be patients with perforations not recognized due to remaining subclinical and spontaneous healing8 or perforations that presented late in a different hospital and , thus , were missed in the follow - up and not included in the above rates .
subclinical perforations described as localized abdominal tenderness and shortlived pyrexia at presentation have proven to be  sealed perforations  at subsequent laparotomy for other reasons . 
 

perforations can result from three principal mechanisms : ( i ) mechanical perforation by colonoscope s tip or shaft - induced lacerations ( loop ) , ( ii ) barotrauma from overinsufflation and ( iii ) therapeutic procedures such as electrocoagulation for polypectomy and laser or argon plasma coagulation due to thermal injury . 
 

colonoscope shaft - induced lacerations may result from any of the following : direct mechanical penetration of the tip of the colonoscope in the bowel wall , especially when visualization is poor ; bowing of a loop of the scope which may cause sufficient lateral pressure to perforate the colonic wall making the perforation invisible from the tip of the instrument ; perforating along a pathologic area of the colon , such as stricture , diverticulum , or tumor , from aggressive air insufflation that may cause colon overdistention and rupture ; and perforating during a snare polypectomy or with direct thermal injury to the bowel wall ( fig . 4 - 7 respectively ) .
immediate operative management , preferably primary repair and sometimes resection , appears to be a good strategy for most patients . 
 

( a ) direct mechanical penetration of the tip of 
 the colonoscope in the bowel wall .
( b ) bowing of 
 a loop of the scope causing perforation of the 
 colonic wall . 
  aggressive air insufflation and colonic wall rupture . 

perforation in a pathologic site , such as stricture , 
 diverticulum , or tumor . 
 

concern over iatrogenic perforation of the gastrointestinal tract during instrumentation relates to the potential spillage of enteric contents into the abdominal cavity , resulting in peritonitis , possible sepsis and even death if there is undue delay in diagnosis and treatment .
plain films of the abdomen and an upright chest x - ray may reveal extravasated air confined to the bowel wall , free intraperitoneal air , retroperitoneal air , subcutaneous emphysema , or even a pneumothorax ( fig .
traditionally , iatrogenic colon perforations were treated with prompt open laparotomy , colonic repair , resection or both , and peritoneal lavage .
surgery is the standard therapy for endoscopic perforations of the colon , but it has a negative psychological and physical impact on a patient referred for a diagnostic test .
more recently , there have been reports of successful laparoscopic repairs endoluminal and transluminal surgery ( i.e. , by metallic endoclipping ) or nonoperative management   in highly selected patients who do not exhibit signs of peritoneal contamination or abdominal sepsis .
surgery is most definitely indicated in the presence of 
 a large perforation demonstrated either colonoscopically or radiographically , in the setting of generalized peritonitis or ongoing sepsis , with concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma , unremitting colitis , or in perforation proximal to a nearly obstructing distal colonic lesion . finally , in the patient who deteriorates with conservative management , one should proceed with surgery . 
 

the endoscopist can provide important information about the quality of the patient s bowel preparation and often a description of the endoscopically visualized injury .
visualization of the peritoneal cavity by the endoscopist and the development of signs of peritoneal irritation are absolute indications for surgery .
endoscopic closure of the iatrogenic colonic perforation is manageable if the diameter of the lesion is smaller than the opened branches of the endo - clips ( 11 mm ) . on the other hand , endoclips creates successful mucosal and submucosal apposition , while apposition of muscularis propria and serosa are not possible .
these patients require further conservative treatment with no oral intake and intravenous broad - spectrum antibiotics and careful assessment during the observation period following the procedure .
bowel preparation , diagnostic versus therapeutic colonoscopy , interventions performed , underlying disease process , clinical patient history , and clinical status after the perforation , radiologic studies and laboratory data , and timing of recognition of the perforation are some of the variables that have to be taken into account when selecting the optimal treatment modality .
treatment using laparoscopic methods is a novel approach , only described in the recent literature .
laparoscopic surgery has decreased trauma and improved results of surgery in postoperative pain control , less perioperative morbidity , smaller incisions , decreased length of hospital stay , rapid return to activity and work , patient satisfaction and cosmetic results . despite this , there have only been small case series which compare laparoscopy to open techniques . if a colonoscopic perforation is to be repaired laparoscopically instead of diverted , the same conditions should be met as during open surgery .
the abdomen should be relatively clean and free of fecal soilage and inflammation , and there should also be no residual pathology
. the operating surgeon and team should be comfortable with laparoscopic techniques , such as mobilization of the colon and intracorporeal suturing .
the defect size and the condition of the bowel to be repaired and the level of contamination and inflammation present are important factors to choosing type of repair .
the method of closure is based on surgeon preference but should be comparable to open techniques . 
 
 in those cases where it is feasible and the surgical skills exist , laparoscopic treatment of iatrogenic colon perforation would result in equal therapeutic efficacy to open surgery and should probably be the initial clinical approach .
extensive inflammation or fecal soilage may require colonic diversion . in difficult or complicated situations with inability to laparoscopically localize the area of perforation and in cases with any doubt regarding the security of the repair , conversion to an open procedure should be performed . for small perforations
, clipping can result in mucosal and submucosal healing , preventing fecal soiling of the peritoneal cavity and could be a helpful adjunct to conservative treatment , thus lowering the need for surgical intervention with its risks .
   iatrogenic perforation of the colon during elective colonoscopy is a serious complication . 
 surgical treatment remains the standard of care . 
 we report a patient with a large colonic perforation that occurred during a screening colonoscopy , successfully repaired with laparoscopic methods . 
 although the safety and efficacy of this approach is not entirely established , laparoscopy can be used to treat iatrogenic colonic perforation when the defect is readily recognized , easily accessible for closure and the bowel preparation is excellent . a laparoscopic approach to treat iatrogenic colon perforation results in decreased morbidity and hospital stay , in addition to a shorter incision length compared to an open method . in those cases where it is feasible and the surgical skill exists 
 , a laparoscopic attempt at colon repair should probably be the initial clinical approach .. 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST