Endoscopic marking

An adjunct to laparoscopic gastrointestinal surgery

R. I. Beretvas,1 J. Ponsky,2

1 Division of General Surgery, Saint Louis University, 3635 Vista Avenue, St. Louis, MO 63110, USA2 Department of General Surgery, Cleveland Clinic, A Building, 8th Floor, East 100th Street, Cleveland, OH 44195, USA

Received: 7 December 1999/Accepted in final form: 8 June 2000/Online publication: 5 July 2001

AbstractBackground:In 1975 one of us (J.P.) first described endo-scopic marking of the intestinal lumen with india ink toproduce a serosal tattoo, thus facilitating the location oflesions during subsequent surgery. The use of the techniquein concert with laparoscopic surgery is particularly impor-tant because the ability to palpate the bowel is lost. Carbon-based products such as india ink provide permanent mark-ing. An alternative marker is methylene blue, whose mark isonly temporary but clearly seen laparoscopically.Methods:We have used methylene blue for intraoperativemarking, reserving India ink for instances in which markingendoscopy occurs before surgery.Results:15 patients, over a period of 2 years, had endo-scopic marking performed preoperatively or intraopera-tively. All markings were easily visualized upon laparosco-py, assisting identification of the sites of the lesions. Nu-merous other cases were marked at endoscopy but did notcome to surgery.Conclusion:Endoscopic marking is an invaluable tool in theperformance of laparoscopic gastrointestinal surgery.

Key words: Endoscopic marking — Endoscopy — Indiaink — Laparoscopy — Methylene blue — Tattoo

Multiple references have confirmed the utility of endo-scopic marking with either methylene blue or india ink[1–10]. This technique has been described previously foruse in “open” surgery [2, 4–6, 9, 10]. A natural evolution inthe use of the method is preoperative tattooing for laparo-scopic gastrointestinal surgery.

Methods

Patients undergo a routine bowel preparation the day preceding endoscopy.They then submit to endoscopy, and suspicious lesions are marked with the

marker of choice. The area of the lesion is marked in four quadrants tofacilitate identification at the time of surgery. Experience has shown thatwithout a four-quadrant marking technique, it is easily possible for themarking to be invisible [6]. This problem could be related to the placementof the markings on the mesenteric border, a possibility that can be avoidedby the use of the four-quadrant technique.

The marking itself is performed in a fashion described previously [1–4,6, 9, 10]. The mucosa is injected with 1 to 2 ml of india ink and water ina 1 to 10 dilution, or with methylene blue. The injection needle is advancedtangentially to the mucosa to avoid injection into the peritoneal cavity. Asmall wheal is raised at the time of injection. Endoscopic marking can beperformed at the time of the laparoscopic procedure or before surgery. Thetype of marker used will be determined by the timing of the endoscopy. Ifthe endoscopy is performed intraoperatively, methylene blue is a suitablemarker because it is water soluble and present only for a short time. Indiaink, however, is more permanent and therefore suitable for use if theendoscopy is performed preoperatively. The laparoscopic procedure then isperformed, and the lesion can be identified by visualizing the staining ofthe serosal surface at the site.

Conclusions

Without the use of marking, laparoscopic identification ofintraluminal lesions can be impossible because there may beno visible serosal signs of the lesion. Also, in contrast to“open” surgery, the possibility of identifying the lesion bytactile sensation is essentially lost.

Endoscopic measurements of lesion sites have been no-toriously unreliable for intraoperative identification. Thisresults from a combination of factors including the telescop-ing of the lumen over the endoscope and difficulty in iden-tifying landmarks. Marking the area can avoid the uncer-tainty associated with estimation using measurements ofscope travel. We therefore propose that endoscopic markingcan be a useful adjunct to laparoscopic surgery.

References

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Surg Endosc (2001) 15: 1202–1203DOI: 10.1007/s004640000304

© Springer-Verlag New York Inc. 2001

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