Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach.

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.

INTRODUCTION

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.[34] During laparoscopy, the colonoscopic perforation is identified and is either sutured or stapled.[56] 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

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

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

Figure 3

Laparoscopic view of the perforation site

Figure 4

Laparoscopic view of exteriorisation of perforation

DISCUSSION

The most feared complication after colonoscopic polypectomy is perforation which may be prevented by laparoscopy-assisted endoscopic polyp excision[78] 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

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.