the unfortunate complication of a colotomy resulting from a colonoscopic polypectomy can be disastrous . using the versatility of laparoscopic surgery
we report a case of cecal perforation , in a 70 year old female , following colonoscopic polypectomy that was treated successfully with laparoscopic application of an endo - gia linear stapler .
four months following staple resection of her cecal perforation , the patient is asymptomatic and has undergone a repeat colonoscopy without any sequelae .
laparoscopic techniques can be safely applied in the treatment of colonic perforations following therapeutic polypectomies .
a suggested management algorithm is provided highlighting the role laparoscopy may provide in selected patients .
colon perforation during therapeutic colonoscopy has been estimated to occur at a rate of approximately 0.1% to 0.3% .
perforation may occur through a variety of mechanisms , including energy application at the polyp site , direct mechanical trauma from the tip of the endoscope , lateral pressure from the side of a bowed endoscope , and pneumatic injury from overinsufflation .
several case reports advocating laparoscopic repair of colonic perforation following colonoscopy have been described in the literature . in our present case report
, we discuss the single application of an endoscopic linear stapler to close the perforation while preserving colonic lumen integrity in the presence of endoscopically placed mucosal clips .
a 70-year - old caucasian female with a past medical history significant for sigmoid diverticulosis and previous benign polyps of the colon was found to have a lipomatous lesion in the ascending colon during routine surveillance colonoscopy .
a complete resection of the polyp was performed using a 15-ml saline injection with india ink lift and a hot snare .
after resection , the mucosal biopsy site was larger than anticipated , and it became difficult to maintain insufflation .
the procedure was halted secondary to progressive abdominal pain and the clinical suspicion of a colonic perforation .
the perforation was confirmed with the presence of substantial free air on radiographs . in this rare situation of early discovery and hemodynamic stability ,
the patient was taken immediately to the operating room for surgical repair . in the operating theater ,
pneumoperitoneum was established with a veress needle , and a 5-mm camera with an optical access trocar was placed in the left lower quadrant . of note , the abdominal pressure at initial access was measured at 10 mm hg , consistent with pneumoperitoneum from insufflation through the colotomy .
a 5-mm anterior perforation of the cecum was clearly visible with an area of circumferential coagulation extending approximately 2 mm ( figure 1a ) .
the cecum was noted to be adhered to the side wall , and hence one additional 5-mm port and one 10-mm port were placed for mobilization in the midline .
the ports were placed in the umbilicus and the suprapubic position . after a sufficient segment of the cecum was freed , a single 30 silk stitch was placed to provide temporary closure and to provide a handle for elevation of the cecum .
an endo - gia 60-mm blue load was applied to preserve the lumen of the cecum while incorporating the entirety of the defect including the area of coagulation necrosis ( figure 1b ) .
the suture line incorporated healthy pink mucosa with preservation of the colonic lumen ( figure 1c ) .
the patient had an uncomplicated recovery with discharge on hospital day 4 . at the 4-month follow - up ,
the patient is without any complaints , tolerating a regular diet , and at baseline health .
she has had an interval surveillance colonoscopy without any abnormalities and a well - healed polypectomy / surgical site .
a : anterior cecal perforation with surrounding circumferential area of necrosis and endoscopically placed clips ( white arrows ) .
b : endo - gia 60 mm stapling with careful preservation of colonic lumen with incorporation of the entirety of the defect and area of coagulation necrosis .
colotomy that occurs during colonoscopy is a specialized subset of colon perforations for a variety of reasons . to begin with , in many cases
the patient is under the care of a physician in a monitored setting with established intravenous access .
although there may be some question as to the precise benefits of mechanical preparation in elective colorectal surgery , in the emergent setting it may be advantageous in minimizing the amount of gross spillage .
in addition , the endoscopist may provide localization of the suspected injury , allowing for more directed treatment .
it has been advocated by some that colonoscopic polypectomy should be performed in conjunction with laparoscopy when a particularly difficult or suspicious polyp is anticipated . in keeping with the success of previous case reports and advances in minimally invasive techniques , we propose an active role of laparoscopy in complex colonoscopies as outlined in figure 2 .
perforations , depending upon their size , may be treated with direct suturing , staple resection or segmental resection .
our approach to this cecal perforation was fundamentally the same as that for an appendectomy .
the technical skills involved in the procedure are well within the capabilities of practicing general surgeons , but several technical tips merit further comment . in this case , primary repair with intracorporeal suturing was technically possible .
however , it seemed ill advised , given the visible zone of coagulation necrosis surrounding the defect . in regards to the surgical stapler
, it would have been technically easier to place a single firing across the cecum rather than 2 angled applications ; however , 2 factors suggested multiple stapling : the endoscopically placed clips may have interfered with proper staple line creation , and a single firing raised the concern for luminal compromise .
it may be argued that in this case the procedure was effective , but that minimally invasive techniques are not broadly applicable .
however , in the analogous situation of perforated appendicitis , there have been multiple studies in which laparoscopy does not have an increased rate of complications over open laparotomy .
conceptually , it seems there is little harm in starting with a diagnostic laparoscopy and proceeding based on the nature of the injury and the experience of the surgeon .
many general surgeons will be confronted with the problem of colon perforation during colonoscopy . in the case
presented here , we modified the established technique of laparoscopic appendectomy to the specific problem of cecal perforation and have demonstrated the feasibility of such an approach .
 background and objectives : the unfortunate complication of a colotomy resulting from a colonoscopic polypectomy can be disastrous . using the versatility of laparoscopic surgery 
 , we aim to provide a treatment algorithm for these colonoscopic perforations.methods:we report a case of cecal perforation , in a 70 year old female , following colonoscopic polypectomy that was treated successfully with laparoscopic application of an endo - gia linear stapler.results:four months following staple resection of her cecal perforation , the patient is asymptomatic and has undergone a repeat colonoscopy without any sequelae.conclusions:laparoscopic techniques can be safely applied in the treatment of colonic perforations following therapeutic polypectomies . 
 a suggested management algorithm is provided highlighting the role laparoscopy may provide in selected patients . 