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Background: Colonoscopic perforation (CP) has a low incidence rate. However, with the extensive use of colonoscopy, even low incidence rates should be evaluated to identify and address risks. Information on CP is quite limited in China. Objective: Our study aimed to determine the frequency of CP in colonoscopies performed by surgeons at a large teaching hospital in China over a 12-year period. Methods: A retrospective review of medical records was performed for all patients who had CPs from 1 January 2000 to 31 December 2012. Iatrogenic perforations were identified mainly by abdominal X-ray or computed tomography scan. Follow-up information of adverse events post-colonoscopy was identified from the colorectal surgery database of our hospital. Patients' demographic data, colonoscopy procedure information, location of perforation, treatment, and outcome were recorded. Results: A total of 110,785 diagnostic and therapeutic colonoscopy procedures were performed (86,800 diagnostic cases and 23,985 therapeutic cases) within the 12-year study period. A total of 14 incidents (0.012 %) of CP were reported (seven males and seven females), of which nine cases occurred during diagnostic colonoscopy (0.01 %) and five after therapeutic colonoscopy (three polypectomy cases, one endoscopic mucosal resection, and one endoscopic mucosal dissection). Mean patient age was 67.14 years. One case of CP (7.14 %) after colonoscopy polypectomy was treated using curative colonoscopy endoclips. Other patients underwent operations: six cases (46.15 %) of primary repair, four cases (28.57 %) of resection with anastomosis, and two cases (15.38 %) of resection without anastomosis. No obvious perforation was found in one patient (7.69 %). Surgeons attempted to treat one case laparoscopically but eventually resorted to open surgery. The postoperative course was uncomplicated in eight cases (57.14 %) and complicated in six cases (42.86 %) but without mortality. Conclusion: CP is a serious but rare complication of colonoscopy. A perforation risk of 0.012 % was found in our study. The optimal management of CP remains controversial. Treatment for CP should be individualized according to the patient's condition, related devices, and surgical skills of endoscopists or surgeons. Selective measures such as colonoscopy without intravenous sedation and decrease of loop formation can effectively reduce rates of perforation. [ABSTRACT FROM AUTHOR]