Endoscopic Tattooing to Mark Distal Margin for Laparoscopic Rectal Resection

Daniel D Kirchoff, MD, Joon Ho Jang, MD, Vesna Cekic, RN, Kathy Baxter, RN, Pranat Kumar, MD, Koji Park, MD, Kevin Holzman, MD, Richard L Whelan, MD. St. Luke’s-Roosevelt Hospital Center

Introduction: Colonic tattoos are routinely used to facilitate laparoscopic localization of colonic neoplasms. Tattoos are not commonly used for rectal cancers. Although it is easy to localize a rectal cancer via endoscopy, when dividing the rectum distally it is difficult to determine how far the stapler is positioned from the tumor’s edge. We propose the use of rectal wall tattoos placed via flexible endoscopy in the OR to mark the distal transection point. Methods: A thin piece of tape is placed on an endoscopic biopsy forceps so that the edge of the tape is 5 cm from the tip of the forceps. A double channel flexible endoscope is then inserted transanally, preferably using CO2 gas for insufflation, and the lesion located. Next, after pulling the scope back from the lesion 3 cm or so, the biopsy forceps is inserted via one working channel and the tip placed at the distal edge of the tumor. The scope is then slowly withdrawn while the biopsy forceps is maintained at the lesion until the tape is visible on the forceps. A 1 cc tattoo (india ink or other dye) is then made in the rectal wall adjacent to the tape mark via a sclerotherapy catheter inserted through the scope’s second working channel. Three additional tattoos are placed at the same level in the other quadrants. The scope is then removed and the transabdominal operation begun. In the course of TME rectal mobilization, the tattoos are usually visible through the mesorectum, alerting the surgeon that this is the transection point. The rectum is mobilized to the pelvic floor level after which the rectum and mesentery are divided at the level of the tattoo. If the tattoo cannot be seen via the abdomen then a repeat flexible proctoscopy is done at the time the linear stapler is being placed on the rectum to ensure that the stapler is at the level of the tattoos or below. This method is also useful when doing an APR or mucosal stripping prior to coloanal anastomosis to alert the surgeon as to the location of the distal most rectum during mobilization. In this case the tattoos are placed just above the sphincter via operating anoscope. Results: We have successfully used this method in 9 MIS rectal resections and found it very useful. In 7 cases the tattoos were seen in the course of rectal mobilization whereas in 2 it was necessary to verify the stapler position via repeat proctoscopy. Too large a tattoo creates a dye patch that makes the method less precise. For rectal lesions proximal to a rectal fold this measuring method is problematic. There have been no complications noted, thus far. This method saves time and removes the doubt associated with blindly dividing the rectum distally during the course of a LAR. Future Directions: Additional cases are planned which will permit refinement of the measuring and injection methods as well as determination of the ideal ink volume.

Session: Emerging Technology Poster
Program Number: ETP103
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