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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤ Acknowledgement
 ¤  References
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 Table of Contents     
UNUSUAL CASE
Year : 2011  |  Volume : 7  |  Issue : 4  |  Page : 239-241
 

Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach


Department of Surgery, University Hospital Lewisham, London, SE13 6LH, United Kingdom

Date of Submission06-Sep-2010
Date of Acceptance22-Nov-2010
Date of Web Publication3-Oct-2011

Correspondence Address:
Rajaraman Durai
Department of Surgery, University Hospital Lewisham, London, SE13 6LH
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.85648

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 ¤ Abstract 

Introduction: With the implementation of bowel cancer screening programmes, more and more colonic polyps are detected, requiring hot biopsies or resections with an attendant risk of perforation. Laparoscopy is increasingly performed for assessing colonoscopic perforations, usually repaired by stitching or stapling, which is associated with a risk of a leak from the suture line. Case Report: We describe a novel approach of laparoscopic exteriorisation of a delayed colonoscopic perforation which resolved without any further intervention. Discussion: Laparoscopic perforostomy is an alternative minimally invasive laparoscopic approach which respects all the rules by allowing a single-stage procedure including thorough toilet with defunctioning and diversion.


Keywords: Colonoscopy, colostomy, laparoscopy


How to cite this article:
Durai R, Ng PC. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Min Access Surg 2011;7:239-41

How to cite this URL:
Durai R, Ng PC. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Min Access Surg [serial online] 2011 [cited 2020 Jan 20];7:239-41. Available from: http://www.journalofmas.com/text.asp?2011/7/4/239/85648



 ¤ Introduction Top


Colonoscopic polypectomy is increasingly performed because of the strict implementation of bowel cancer screening programmes. Polypectomy carries a risk of causing perforation of the colon. [1] Often, the perforation is noticed within the first 48 hours and usually the peritoneum is not grossly contaminated as this happens on an already prepped colon. [2] In big colonic perforations, there may be faecal contamination. Laparoscopy is increasingly performed for assessment and treatment of colonoscopic perforation. [3],[4] During laparoscopy, the colonoscopic perforation is identified and is either sutured or stapled. [5],[6] However, this form of treatment is associated with a risk of leak from the suture line. [6] The authors encountered an unusual case of a colonic perforation which occurred after 8 weeks, following polypectomy. In this article, we describe a novel approach to the problem by exteriorising the perforation without suture or stapling.


 ¤ Case Report Top


A 60-year-old woman presented with a sudden onset of severe abdominal pain. Her medical history included colonoscopy and sigmoid polypectomy [Figure 1] eight weeks prior to her presentation. The polypectomy was for a 3.5-mm pedunculated benign adenomatous polyp. The operation note described it as diathermy snared without difficulty [Figure 1]. It did not require saline injection to lift the base. There was no evidence of diverticular disease. Between her polypectomy and her presentation, she had been opening her bowels normally and had been asymptomatic. On admission, her abdomen was diffusely tender with guarding in the right iliac fossa. Blood tests showed a neutrophilic leucocytosis and an elevated C reactive protein. An erect chest X-ray showed air under the diaphragm. She was taken to theatre for a diagnostic laparoscopy.
Figure 1: Colonoscopic view of the polyp stalk after polypectomy

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Laparoscopic perforostomy

With a Veress needle which was inserted against controlled subumbilical traction, a pneumoperitoneum was induced. A 10-mm port was inserted in the subumbilical region carrying a 30 degree-angled telescope. Two 5-mm ports were then inserted in the left iliac fossa and supra pubic region . Laparoscopy showed frank pus of about 300 ml in the pelvis [Figure 2], and a normal looking appendix, with serosal inflammation of the terminal ileum. Meticulous examination showed a fibrinous area on the antemesenteric border of the sigmoid colon [Figure 3]. Exploration of this area confirmed the presence of a perforation measuring 5 mm, within the fibrinous area, presumably from the previous polypectomy which had sealed and re-perforated. The sigmoid loop was found to be mobile and free from diverticulae. The 5 mm port site in the left iliac fossa was enlarged by making an incision on either side. The perforated area was exteriorised [Figure 4] by holding the bowel with a laparoscopic Babcock forceps at the same time withdrawing the port and forceps as one unit while deflating the abdomen. Re-insufflation enabled thorough peritoneal toilet and drainage. The healthy serosa around the perforation was stitched to the fascia and the mucosa stitched skin with undyed 3 0 vicryl. A stoma bag was applied and the drain removed after 48 hours, allowing the patient to go home.
Figure 2: Laparoscopic view showing pelvic abscess

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Figure 3: Laparoscopic view of the perforation site

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Figure 4: Laparoscopic view of exteriorisation of perforation

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 ¤ Discussion Top


The most feared complication after colonoscopic polypectomy is perforation which may be prevented by laparoscopy-assisted endoscopic polyp excision [7],[8] and clipping of the base of the pedunculated polyps. Removal of sessile polyps is associated with a higher risk of perforation when compared to polyps with a long pedicle. Saline injection of the base may lift the polyp and often helps in reducing the risk of bowel perforation. Conventional teaching advises to perform a laparotomy, washout the peritoneal cavity for colonoscopic perforations and stitch the perforation primarily. [9] Sometimes, it may result in leakage and require subsequent laparotomy. [4] Rarely, it may not be possible to locate the perforation laparoscopically, which means that the procedure has to be converted to a laparotomy. [6]

In our patient, the perforation occurred two months after polypectomy, and the perforostomy functioned like a controlled fistula which is a minimal access approach, not reported before. Since this perforation was not fresh, a primary closure would have been risky and the alternative staged procedures recommended by conventional wisdom would have been to resect, defunction or possibly perform a Hartmann's procedure with formal faecal diversion. In this case, exteriorisation helped to avoid a potential leak from a suture line and allowed the bowel to heal with minimal disturbance to its physiology while respecting the principles of diversion. It also allowed daily monitoring of the perforated area. At follow-up, three months later, the fistula had closed spontaneously [Figure 5].
Figure 5: Five months after perforostomy showed the stoma has closed by natural mechanisms

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The perforostomy, which initially functioned as a stoma, later as a controlled fistula, eventually spontaneously closing after three months, demonstrates the principle that a fistula without distal obstruction will eventually close. The simple procedure took less than 30 minutes to perform, avoided a laparotomy and a Hartman's procedure, a formal two-stage classic faecal diversion followed by reversal with its own potential complications. We have used the laparoscopic approach with primary closure successfully on previous occasions in fresh stercoral, diverticular and foreign body perforations with a mobile sigmoid loop. [10] The advantage of this approach is undoubtedly to allow full access to the pelvic areas for meticulous toilet. The obvious limiting disadvantage of this approach is whether the perforated area will reach the anterior abdominal wall without tension. Although we are not suggesting that all fresh colonoscopic perforations should be treated this way, we believe laparoscopic perforostomy is an alternative, minimally invasive laparoscopic approach which respects all the rules by allowing a single-stage procedure which defunctions and diverts, and allows thorough peritoneal toilet. This method would be suitable for high-risk patients in order to avoid a major resection and the patients should be consented explaining that they may still need a resection at a later date.


 ¤ Acknowledgement Top


The authors are grateful to the patient for allowing publication of the images relating the procedure.

 
 ¤ References Top

1.Tiwari A, Melegros L. Colonoscopic perforation. Br J Hosp Med (Lond) 2007;68:429-33.  Back to cited text no. 1
[PUBMED]    
2.Mattei P, Alonso M, Justinich C. Laparoscopic repair of colon perforation after colonoscopy in children: Report of 2 cases and review of the literature. J Pediatr Surg 2005;40:1651-3.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Schlinkert RT, Rasmussen TE. Laparoscopic repair of colonoscopic perforations of the colon. J Laparoendosc Surg 1994;4:51-4.  Back to cited text no. 3
[PUBMED]    
4.Alfonso-Ballester R, Lo Pez-Mozos F, Mart-Obiol R, Garcia-Botello SA, Lledo-Matoses S. Laparoscopic treatment of endoscopic sigmoid colon perforation: A case report and literature review. Surg Laparosc Endosc Percutan Tech 2006;16:44-6.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hayashi K, Urata K, Munakata Y, Kawasaki S, Makuuchi M. Laparoscopic closure for perforation of the sigmoid colon by endoscopic linear stapler. Surg Laparosc Endosc 1996;6:411-3.  Back to cited text no. 5
[PUBMED]    
6.Hansen AJ, Tessier DJ, Anderson ML, Schlinkert RT. Laparoscopic repair of colonoscopic perforations: Indications and guidelines. J Gastrointest Surg 2007;11:655-9.  Back to cited text no. 6
    
7.Averbach M, Cohen RV, de Barros MV, Kawahara NT, Ferreira EA, Pereira PR, et al. Laparoscopy-assisted colonoscopic polypectomy. Surg Laparosc Endosc 1995;5:137-8.  Back to cited text no. 7
[PUBMED]    
8.Ommer A, Limmer J, Mollenberg H, Peitgen K, Albrecht KH, Walz MK. [Laparoscopic-assisted colonoscopic polypectomy--indications and results]. Zentralbl Chir 2003;128:195-8.  Back to cited text no. 8
    
9.Volpe A, Piccoli M, Colli G, Mecheri F, Melotti G. [Laparoscopic treatment of colonoscopic perforation: A case report]. Chir Ital 2007;59:587-90.  Back to cited text no. 9
[PUBMED]    
10.Arora S, Ashrafian H, Smock ED, Ng P. Total laparoscopic repair of sigmoid foreign body perforation. J Laparoendosc Adv Surg Tech A 2009;19:401-3.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

This article has been cited by
1 Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach
Vagholkar, K.
Journal of Minimal Access Surgery. 2012; 8(2): 65-66
[Pubmed]



 

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