The utilization of laparoscopic modalities has demonstrated to result in diminished selleck Pazopanib surgical trauma, lower conversion rates, reduced complication rates, and quicker recovery with shorter length of hospital stay compared with open surgery [5�C7]. 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, 15�C17]. 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 GSK-3 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 withCO2 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.