Live Case - Perforation Management After Colorectal Polypectomy

Overview

Perforation is a complication every colonoscopist must be prepared to manage. In this 28-minute live case, a significant perforation following underwater polypectomy at the splenic flexure is managed from haemostasis to final clip closure — with expert dual commentary narrating every decision as it unfolds, including moments where clips fail and the team diagnoses the failure mode out loud.

Key Learning Points

• Haemostasis before closure. When extraluminal bleeding is present, attempting closure first risks losing access permanently. Address active bleeding first — even while the perforation remains open and enlarging.
• Escalate to Kerr grasper when snare tip coagulation fails. Omental fat accumulates coagulum and prevents effective diathermy contact. Recognise the failure pattern early and switch tools.
• Clip stem positioning is the critical variable. The stem must run exactly along the perforation line with legs perpendicular to maximise tissue capture across the full defect depth.
• Start on the gravity-dependent side and suction maximally before deploying each clip. Once a good position is achieved after suction, trust it and deploy — repositioning releases the advantage you just created.
• High-density clip closure: successive clips placed flush with no gap between them achieve the tissue apposition required for complete closure of large defects.
• Recognise clip failure modes and switch clip type. When two consecutive clips fail for the same reason, switching to a different design (e.g. Instinct) provides greater closure force.

Clinical Relevance

The transparency of this case is its greatest teaching value. The instructors narrate uncertainty, diagnose errors in real time, and stay calm and adaptive throughout. The overriding message: "Pretty much everything in endoscopy is lost in poor decision-making, including time." Even a technically demanding, stressful perforation can be resolved endoscopically when systematic thinking is maintained.

Who Should Watch

All endoscopists performing polypectomy or advanced resection who need to be confident in perforation recognition and clip closure technique. Particularly valuable for those who have not yet encountered a significant perforation and want to rehearse the decision-making framework before they do.