Hybrid Endoscopic-Laparoscopic Management of Colonoscopic Perforation within an Inguinal Hernia Sac

Summary

This case report demonstrates a multidisciplinary management pathway for a rare iatrogenic colonic perforation entrapped within an inguinal hernia sac, using a hybrid strategy of immediate endoscopic closure followed by definitive laparoscopic resection.

Abstract

Colonoscopy is the gold standard for colorectal cancer screening, yet it carries the risk of iatrogenic perforation. A rare, hazardous subtype involves colonoscope incarceration and perforation within an inguinal hernia sac, mechanically driven by a "hinge effect" during withdrawal. The confined anatomical space often masks typical peritoneal signs, challenging diagnosis. A case is presented of a 71-year-old male (Body Mass Index: 24.2 kg/m²) undergoing a routine screening colonoscopy. Significant resistance occurred at the sigmoid colon during withdrawal, revealing a 1.0 cm full-thickness defect. First, an immediate endoscopic "damage control" strategy was employed using a through-the-scope purse-string suture technique combining a nylon endoloop with titanium clips to seal the defect acutely within 15 min. Crucially, an emergency contrast-enhanced Computed Tomography (CT) scan performed at Hour 1:00 post-event identified the perforated segment entrapped within a 4 cm left inguinal hernia sac, suggesting surgical exploration over exclusive conservative observation due to visceral ischemia risks. Consequently, the patient underwent laparoscopic partial sigmoidectomy of a 10 cm segment and high ligation of the hernia sac with internal ring closure under a stable 12 mmHg pneumoperitoneum (operative duration: 165 min; blood loss: 15 mL). The patient recovered uneventfully and was discharged on the seventh postoperative day. Quantified follow-up at 1 and 3 months confirmed complete functional recovery and zero recurrence. This case highlights the need for pre-procedural hernia assessment and suggests that a hybrid approach, pairing immediate endoscopic containment with planned surgical repair, may present a feasible alternative pathway for managing this rare emergency.

Introduction

Colonoscopy is widely regarded as the gold standard for colorectal cancer (CRC) screening, diagnosis, and therapeutic intervention. With the global scale-up of CRC screening initiatives, the number of colonoscopic procedures has risen dramatically. Although colonoscopy is generally safe, it remains an invasive procedure inherently associated with procedural risks. Perforation, identified by the American College of Gastroenterology (ACG) quality indicators as one of the most severe adverse events, occurs in 0.01%–0.1% of diagnostic colonoscopies and up to 0.3% of therapeutic procedures^1,2. Most iatrogenic....

Protocol

This clinical protocol was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of The First Hospital of PuTian City (Approval No. 2024-168). Written informed consent was obtained from the study participants. The reagents and the equipment used are listed in the Table of Materials.

1. Pre-procedural risk assessment and preparation

1. Elderly male patients were systematically screened for a history of abdominal wall or inguinal hernias via physical palpation and medical chart review before initiating the colonoscopy.
2. Specific iatrogenic ris....

Results

The patient was an elderly male with a Body Mass Index (BMI) of 24.2 kg/m² and an American Society of Anesthesiologists (ASA) physical status of Class II. He underwent a routine screening colonoscopy utilizing standard room air insufflation. The colonoscopy proceeded smoothly to the cecum without mucosal abnormalities. However, during the withdrawal phase, specifically at approximately 30 cm from the anal verge (sigmoid colon region), the operator detected a transient increase in resistance. Upon detailed insp.......

Discussion

This case illustrates a rare yet mechanistically distinct form of iatrogenic injury: sigmoid colon incarceration followed by perforation within an inguinal hernia sac during colonoscopy¹. Although colonoscopy remains the gold standard for colorectal cancer (CRC) screening, diagnosis, and intervention, perforation constitutes its most severe procedural complication. According to consensus quality indicators from the American College of Gastroenterology (ACG) and the American Society for Gastrointes.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable Suture (1#)	Ethicon (Johnson & Johnson)	VCP359H	Coated synthetic polyglactin absorbable suture (USP 1) utilized for fascial closure. Referred to as "absorbable suture" in text.
Carbon Dioxide (CO2) Insufflator	Olympus	UCR	Standard CO2 regulation unit for medical endoscopic procedures. Referred to as "CO2 insufflator" in text.
CT Scanner	Neusoft Medical Systems	NeuViz 128	Multi-detector computed tomography (MDCT) system for diagnostic imaging. Referred to as "MDCT scan" in text.
Endoloop (Nylon Loop)	Olympus	MAJ-254	Pre-tied nylon loop ligating device with a 30 mm diameter loop. Referred to as "endoloop loop delivery device" in text.
Endoscopic Titanium Clips	Olympus	HX-610-090	Rotatable through-the-scope titanium hemostatic clips. Referred to as "titanium clips" or "endoclips" in text.
Laparoscopic Imaging System	Olympus	Visera 4K	High-definition 4K laparoscopic camera control unit and tower. Referred to as "laparoscopic system" in text.
Laparoscopic Trocars	Ethicon (Johnson & Johnson)	B5LT / B12LT	Bladed and bladeless surgical trocars (5 mm and 12 mm diameters). Referred to as "laparoscopic trocars" in text.
Linear Cutter Stapler	Ethicon (Johnson & Johnson)	TLC55 / TLC75	Heavy-duty linear surgical cutter and stapler for gastrointestinal tract reconstruction. Referred to as "linear cutting stapler" in text.
Negative Pressure Drainage Tube	Pacific Hospital Supply	Simplastic	Medical silicone round negative-pressure drainage system. Referred to as "pelvic silicone drain" in text.
Silk Suture (1-0)	Ethicon (Johnson & Johnson)	EH7350H	Non-absorbable braided silk surgical suture (USP 0). Referred to as "silk suture" in text.
Ultrasonic Scalpel	Ethicon (Johnson & Johnson)	HARH36	High-frequency ultrasonic surgical shears for soft-tissue dissection and coagulation. Referred to as "ultrasonic scalpel" in text.
Veress Needle	Ethicon (Johnson & Johnson)	UV120	Sterile single-use pneumoperitoneum needle (120 mm length). Referred to as "pneumoperitoneum needle" in text.
Video Colonoscopy System	Olympus	CF-H290I	High-definition single-channel electronic video colonoscope. Referred to as "standard colonoscope" in text.