Difficult laparoscopic total mesorectal excision after preoperative colonoscopic tattooing

Abstract

Endoscopic tattooing with India ink is widely used for tumor localization. Widespread application of laparoscopic colorectal surgery enhances the significance of endoscopic tattooing.1 Here, we report a case of difficult laparoscopic total mesorectal excision with India-ink leakage after endoscopic tattooing. A 68-year-old male patient was referred to our hospital for rectal-cancer surgery. Colonoscopy revealed a 2-cm elevated tumor at the anterior wall of the lower rectum. Two-point tattoos were noted around the tumor (Fig. 1A,B). During robotic-assisted laparoscopic surgery 3 weeks after tattooing (at a different hospital), a diffuse macular streak of black pigment was evident at the rectal wall, peritoneum, mesorectum, and extramesorectum. This streak complicated identification of the appropriate surgical dissection plane (Fig. 1C). Careful dissection enabled uneventful completion of surgery. The key to total mesorectal excision is sharp dissection within the surgical dissection plane between the visceral and parietal pelvic fascia.2 Endoscopic submucosal dissection (ESD) and total mesorectal excision both require precise dissection within the targeted layer under direct vision. Increased difficulty with ESD as a result of deteriorated endoscopic view and submucosal fibrosis after tattooing has been reported.3 The present case illustrates peritoneal leakage by deep injection of ink that hampered clear visualization of the appropriate dissection line, which increased technical difficulty in subsequent surgery (Fig. 2). Although saline test injection methods may reduce the risk of spillage, leakage rates with this method are unsatisfactory (9.5–14.3%).4, 5 This case suggests that improvements in endoscopic tattooing are necessary to avoid deep injection and peritoneal ink leakage. Notably, international consensus to guide endoscopic tattooing is absent. Considerations should be given to the justification for its application and more attention should be paid to standardize its methodology including injection technique, injected substances, volume, number, and location for marking. Surgeons and endoscopists should develop consensus to encourage uniform practice for assured performance. Authors declare no conflicts of interest for this article.