iatrogenic perforation represents an uncommon yet potentially life - threatening complication during colonoscopy [ 1 , 2 ] . traditionally , patients have required open surgery with either primary repair of the perforation or bowel resection with or without ostomy creation [ 1 , 3 , 4 ] . although these procedures are an effective approach , they often require large open incisions and may be associated with high complication rates , such as wound infection and hernias [ 1 , 4 ] . in addition , the open approach usually results in slower recovery with longer hospital stay [ 57 ] . minimally invasive colorectal surgery represents an efficacious alternative to the open approach , utilizing smaller incisions and resulting in diminished postoperative pain , earlier recovery , and lower postoperative morbidity [ 59 ] . laparoscopic intervention has more recently been reported for the definitive treatment of acute colonoscopic perforations . this approach has shown to be a viable option , resulting in enhanced recovery in comparison to open primary colorrhaphy [ 57 ] . we began utilizing minimally invasive surgical ( mis ) technique for repair of colonoscopic perforations in an effort to provide a safe and efficacious alternative to an open procedure . our aim was to assess and report our initial experience with laparoscopic primary repair of acute colonic perforations during colonoscopy . between october 2008 and march 2010 , consecutive patients presenting with acute iatrogenic colonic perforation during colonoscopy were evaluated . laparoscopic surgical repair of the perforations was performed by one of three board - certified colorectal surgeons ( a. mahmood , t. b. pickron , and e. m. hass ) with extensive experience in minimally invasive procedures . preoperative data including age , gender , body mass index ( bmi ) , american society of anesthesiologists ( asa ) score , indication for colonoscopy , and time interval between perforation and surgery were assessed . intraoperative parameters including estimated blood loss ( ebl ) , conversion to open surgery , and complications were collected . with respect to postoperative data , return of bowel function , resumption of oral intake , complications , length of stay ( los ) , secondary interventions , and readmissions within 30 days after discharge were evaluated . initial entry into the peritoneal cavity was achieved under direct visualization using an optiview trocar ( ethicon endo - surgery inc . , an additional two or three 5 mm trocars were utilized with placement dependent on the suspected location of the perforation . laparoscopic exploration was performed and followed by identification and isolation of the site of the colonic perforation . the necrotic edges of the perforation were debrided , and colorrhaphy was performed with interrupted 3 - 0 vicryl ( ethicon inc . an air insufflation test was performed in all cases to confirm the integrity of the repair . five female patients presented with acute iatrogenic colonic perforation , which occurred during screening colonoscopy . the mean age , mean bmi , and median asa of the patients were 71.4  9.7 years ( range : 5883 years ) , 26.4  3.4  kg / m ( range : 21.330.9  kg / m ) , and 2 ( range : 2 - 3 ) , respectively ( table 1 ) . three perforations were secondary to mechanical trauma and recognized during the colonoscopy , while two perforations occurred due to thermal injury and were identified within 24 hours of the colonoscopy . the perforations were located in the sigmoid ( n = 4 ) and cecum ( n = 1 ) . while in 3 cases the time interval between perforation and surgery was 3 - 4 hours , in 2 cases surgery was performed following 18 and 20 hours of perforation . there was no significant blood loss ( range : 050  ml ) or intraoperative complications during the procedures , and none required conversion to open surgery . surgical resection and diversion mean resumption of oral intake and return of bowel function , as evidenced by passage of flatus , were 1.4  0.5 and 1.6  0.9 days , respectively ( range : 1 - 2 days ) . the average length of hospital stay ( los ) was 3.8  0.8 days ( range : 35 days ) . there were no postoperative complications , and none of the patients required readmission or secondary operative intervention ( table 2 ) . although complications during colonoscopy are uncommon , colonic perforation represents a potentially life - threatening event that may result in peritonitis , sepsis , and multiorgan failure , thus demanding prompt diagnosis and intervention . while colonic perforations have traditionally been managed through emergent laparotomy with segmental resection and possible diversion , mis techniques , including laparoscopic segmental resection or primary suture repair and endoscopic suturing or clipping , have more recently been implemented [ 1 , 37 , 1012 ] . the utilization of laparoscopic modalities has demonstrated to result in diminished surgical trauma , lower conversion rates , reduced complication rates , and quicker recovery with shorter length of hospital stay compared with open surgery [ 57 ] . four main mechanisms have been hypothesized in the pathogenesis of colonoscopic perforation : direct penetration of the bowel wall , barotrauma , thermal abrasion , and traction injury [ 3 , 13 , 14 ] . the selection of an appropriate approach for the management of a colonoscopic perforation must be individualized on a case - by - case basis . a history of previous colonic pathology requiring partial colectomy , such as recurrent diverticulitis or neoplastic disease , may preclude consideration of primary repair . lack of optimal bowel preparation prior to colonoscopy or a prolonged interval between perforation and intervention may increase the risk of fecal contamination of the peritoneal cavity . in such cases , resection with diversion may be considered [ 6 , 13 ] . however , preservation of a minimally invasive platform may be accomplished through laparoscopic segmental resection . furthermore , some colonoscopic perforations may be managed with endoscopic clipping or with conservative measures [ 11 , 1517 ] . when identified during the index colonoscopy , endoscopic clipping may be successfully accomplished , avoiding any further intervention and its potential complications [ 11 , 17 ] . delayed colonoscopic perforations are typically due to thermal injury , which are in most cases small perforations . these minor perforations represent the main indication for conservative treatment , which consists of intravenous hydration , antibiotics , and bowel rest . laparoscopic surgery represents an efficient technique for primary colonic repair . during this mis technique , laparoscopic exploration is performed to visualize the perforation and assess the bowel content spillage into the peritoneal cavity . it is important to examine the entire large bowel in order to identify and repair secondary perforations . occasionally , the proper identification of the perforation is not readily achieved ; in such cases , colonoscopic assistance may be required . in this scenario , colonoscopic insufflation with  co2 is preferred over air insufflation , as the former is avidly absorbed through the colonic mucosa , avoiding substantial increment in the intraluminal pressure . minimization of spillage is achieved by clamping the proximal bowel and using steep trendelenburg for right colon perforations or reverse - trendelenburg for left colon perforations . once the colonic wall injury is identified , the edges of the perforation must be debrided if necrotic . this maneuver is challenging when performed laparoscopically , as the surrounding mesentery may be damaged resulting in considerable bleeding . most colonic perforations occur in the antimesenteric bowel border ; however , when the mesenteric bowel border is involved in the perforation , it must be sutured initially to avoid a residual unrepaired wall defect in the mesenteric commissure of the perforation . the colorrhaphy itself consists of interrupted stitches with absorbable suture , usually in one layer to avoid narrowing of the lumen , especially in the sigmoid , and to minimize stretching of the serosal layer ( figure 1 ) . prior to the completion of the procedure , an air insufflation test is recommended to evaluate the integrity of the repair .   in our series , the majority of perforations ( n = 3 ) were secondary to direct penetrating trauma from the tip or shaft of the endoscope . they were recognized during the colonoscopy , and the patients were taken to the operating room within 4 hours of occurrence . laparoscopic exploration revealed absence of significant spillage or peritonitis and presence of viable tissue at the edges of the perforation . two patients developed delayed perforation due to thermal injury . in the first case ( patient 3 ) , the perforation was secondary to polypectomy with argon - plasma coagulation , whereas in the second case ( patient 5 ) , the perforation occurred following ablation of 2 large cecal angiodysplasias . both patients presented to the emergency department within 20 hours of their respective colonoscopies with mild generalized abdominal pain and absence of peritoneal signs on physical exam . following debridement , laparoscopic primary colorrhaphy was successfully performed .   our postoperative outcomes compared favorably with those reported in the published literature . we encountered a mean length of hospitalization of 3.8 days , and there were no postoperative complications . in 2007 , hansen et al . the overall mean los was 7.6 days , and they encountered two ( 28.6% ) postoperative complications . the remaining complication consisted of an intraabdominal abscess secondary to leakage at the site of the colorrhaphy , requiring sigmoid resection and end colostomy creation . in 2008 , rumstadt et al . reported a case series that evaluated 13 cases of primary colon repair for free colonic perforations following colonoscopy . laparoscopic approach was initially attempted in 10 patients ; however , 2 cases required conversion to open technique due to severe peritonitis . this rather prolonged los was in part due to the discouragement of early discharge in the institutions in which the procedures were performed . despite this , the authors reported significantly shorter los for the laparoscopic approach in comparison to the open technique ( 7.1  versus  14.3 days , p = 0.019 ) . in the same year , bleier et al .   published a study comparing outcomes following open and laparoscopic primary repair for the management of iatrogenic colonic perforations . the los was significantly shorter for the laparoscopic group ( 5  versus  9 days , p = 0.01 ) . furthermore , the complication rate was lower in the laparoscopic group ( 2/12  versus  5/7 , resp . , , the authors concluded that the laparoscopic primary repair , when performed by experienced laparoscopic surgeons , is advantageous over the open technique . the present study evaluated the outcomes of our initial experience utilizing laparoscopic primary repair for the treatment of acute iatrogenic colonic perforations during colonoscopy . accordingly , we currently consider this modality as an initial approach for the management of such perforations . if favorable conditions exist ( e.g. , minimal spillage , absence of sepsis ) , we could primarily repair . none of our cases required conversion to open surgery ; however , if the minimally invasive platform proves unsuccessful , a conversion to laparotomy can be readily performed . laparoscopic primary colorrhaphy is a safe and feasible approach for the management of acute colonoscopic perforations . conventional laparoscopic suture repair facilitates a minimally invasive procedure with minimal surgical trauma , rapid postoperative recovery , and low complication rate . consequently , laparoscopic primary colon repair may increasingly play an important role as a therapeutic option in the future management of various perforations . additional prospective comparative studies will be necessary to further elicit the benefits and limitations of this approach .
purpose . 
 we present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations . 
 methods . over a 17-month period , we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations . 
 patient characteristics and perioperative parameters were tabulated . 
 postoperative outcomes were evaluated within 30 days following discharge . 
 results . five female patients with a mean age of 71.4  9.7 years ( range : 5883 ) , mean bmi of 26.4  3.4  kg / m2 ( range : 21.330.9 ) , and median asa score of 2 ( range : 2 - 3 ) presented with acute colonoscopic perforations . 
 all perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development . 
 the perforations were secondary to direct trauma ( n = 3 ) or thermal injury ( n = 2 ) and were localized to the sigmoid ( n = 4 ) or cecum ( n = 1 ) . none of the patients required surgical resection , diversion , or conversion to an open procedure . 
 no intra- or postoperative complications were encountered . 
 the mean length of hospital stay was 3.8  0.8 days ( range : 35 ) . 
 there were no readmissions or reoperations . 
 conclusion . 
 acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion . 
 early recognition and intervention are essential for successful outcomes .