Audit of preoperative localisation of tumor with tattoo for patients undergoing laparoscopic colorectal surgery

Introduction

Recent reports from the UK cancer institute place colorectal cancer as the third most common cancer in both sexes. Around 110 new cases are diagnosed each day in the UK. In 2008, there were 39,991 new cases registered in the UK, around two-thirds (25,551) in the colon and one-third (14,440) in the rectum. ¹

With the introduction of laparoscopic colorectal surgery over 10 years ago, the technique has become increasingly popular. The benefits of laparoscopic surgery are widely recognised; with earlier recovery of bowel function, less analgesia postoperatively and shorter hospital stays being important advantages over open colorectal surgery. ² Percentage of laparoscopic surgery is on the rise, with 25% of colonic resections being performed laparoscopically in the UK by March 2009. ³

Precise localisation of the site of colonic malignancy is a critical aspect of laparoscopic surgery in order to secure adequate margins and lymphadenectomy. With laparoscopic surgery, it can be quite difficult to locate lesions at the time of surgery, and palpation of the colonic tumour is impossible. Methods of endoscopic injection have been described in the literature.^4–6 Our purpose was to evaluate a technique that can be used during colonoscopy to accurately localise the tumour or lesion to ensure the site of pathology is identified at laparoscopy. We describe our experience with a permanent surgical marker (SPOT) tattoo at the time of colonoscopy. SPOT is a pure carbon-based permanent marker that contains no additives and has been approved for colonic tattooing in the UK. The tattoo is placed at three spots one mucosal fold distal to the lesion.

Patients and methods

It is our practice to inject a SPOT during the initial colonoscopy if a lesion is identified or a polyp which will require further surgical resection or surveillance following endoscopic removal is identified.

Between April 2011 and May 2013, we identified 100 patients who underwent elective laparoscopic colorectal resection for cancer (54 anterior resections, 38 right hemicolectomies, 1 sigmoid colectomy and 7 subtotal colectomies). Excluded were those who had abdominoperineal resections. During colonoscopy, these patients were prospectively marked with 10 ml of SPOT by raising a mucosal bleb at three spots one mucosal fold distal to the lesion. A prospective database was maintained with data regarding presence of tattoo preoperatively as documented in the colonoscopy report, visibility of the tattoo at time of laparoscopy and accuracy in relation to the tumour.

Results

In all 100 patients, the entire colon was examined preoperatively by colonoscopy. None of the patients developed a fever, abdominal pain, or tenderness after tattooing the colon. The mean time interval between the injection of the ink and subsequent operation was three weeks. The longest interval between injection and operation was three months in a patient who had preoperative long course chemoradiotherapy prior to surgery.

Of the 100 laparoscopic resections, there were 12 conversions. Reasons for conversion were due to large tumours, locally advanced tumours and adhesions. One case was converted due to mesenteric bleed that could not be controlled laparoscopically.

In 63 patients, the tattoo was visible intraoperatively, while it was not visible in 37 patients. Of the 37 that were not visible, 20 required on-table endoscopy as the tumours were small and intramucosal. During postoperative examination of the specimens, the tattoo was accurately placed in 59 of the 63 patients, while it was inaccurately placed in four patients. Most of the cases in which no ink was seen occurred early in the series due to learning curves for the endoscopists and use of more superficial injections.

Discussion

Indications for colonoscopic tattooing are for obvious malignant lesions or a completely excised lesion with malignant histology requiring further surgery or surveillance. The technique allows for shortened operative time since the lesions can be rapidly localised. It is also useful in open surgery for localisation of small low rectal tumours as intraoperative palpation can be difficult. Several authors have reported methods of placing the ink to accurately localise the lesion during surgery especially with laparoscopic surgery were palpation is impossible. Botoman et al. ⁷ in their series on 14 patients reported placing the ink at all 90° quadrants since the endoscopist cannot reliably identify the anterior wall of the colon. This produced excellent intraoperative localisation in 11 of their patients.

Use of a permanent ink is a safe and effective method to landmark small lesions in the colon. Several authors have described the use of ‘India ink’ as an effective low budget method of tattooing.^7,8 However, it has been associated with rare complications as described by Botoman, ⁷ which are presumably related to inflammatory responses to additives in the ink. SPOT is a pure carbon-based permanent marker that contains no additives and has been approved in the UK for colonic tattooing. In our institution, most endoscopists use SPOT ink.

Complications such as perforation and abscess formation have been reported. ⁷ Histopathological complications have also been reported such as local reactions like fat necrosis with inflammatory pseudotumour formation and chronic inflammation. ⁹ We had no complications in our series.

With the method adopted in our institution were all endoscopists tattoo all significant lesions found at colonoscopy with three spots of tattoo (SPOT ink) one mucosal fold distal to the lesion, our intraoperative tattoo visibility is similar to that in the published literature^8,10 with no associated complications. Most of the cases in which no ink was seen occurred early our series denoting a learning curve.

Conclusion

Preoperative tumour localisation is extremely important to correctly identify the site of tumour or lesion at laparoscopy. A standardised departmental protocol should be implemented by all endoscopists to place three spots of tattoo one mucosal fold distal to any significant lesions found. Failure to tattoo lesions/cancers preoperatively can lead to intraoperative delays and potential harm to patients from on-table endoscopy.