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therapeutic colonoscopy is a rare but serious complication [1]. It is usually managed with immediate open surgery. However, conservative therapy has recently been advocated [2], provided that adequate precolonoscopic bowel preparation hasbeen carriedout and that noperitoneal signs are present [3]. Asymptomatic perforations after colonoscopic polypectomy have been conservatively managed using close observation, even in the presence of intra-abdominal free air [4]. Recently, endoclip closure was used to treat iatrogenic colonic perforation conservatively [5]; however, endoclipping cannot be used to repair perforations that are larger than the endoclip (diameter 11mm) [5]. We report the case of a large iatrogenic rectal perforation due to endoscopic mucosal resection (EMR) and its subsequent conservative treatment. A 65-year-old woman with a flat 30-mmwide rectal adenoma underwent EMR after injection of 0.4% sodium hyaluronate (●" Fig. 1a). The lesionwas completely removed; however, a 25-mm-wide perforation was noted on the posterior wall at 10 cm from the anal verge. The perforation was too large to be closed by endoclipping, so the marginal mucosa of the perforation was circumferentially attached to the presacral tissue adjacent to the rectum using endoclips (●" Fig. 1b). Computed tomography (CT) revealed free air in the presacral space, but no pneumoperitoneum (●" Fig. 2a). Closure of a rectal perforation by clipping the margins to presacral tissue