Case Report

A Novel Technique for Intraoperative Localization of Colonic

Tumors during Laparoscopic Colectomy: A Case Report and
Review of the Literature
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Sanatan Bhandarkar, Vishakha Kalikar, Meghraj Ingle1, Roy Patankar

Department of Surgery, Zen Multispeciality Hospital, Mumbai, Maharashtra, 1Department of Gastroenterology, LTMGH, Sion, Mumbai, Maharashtra, India
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Abstract
When laparoscopic surgery is selected for gastrointestinal resection, accurate tumor localization is important. We used a C‑arm intraoperatively
in a case where preoperative endoscopic clipping was done at the tumor site. Our patient was an 82‑year‑old man with moderately differentiated
adenocarcinoma in the sigmoid colon. ResolutionTM Clips were applied adjacent to the lesion on the proximal and distal ends. Intraoperatively,
the growth over the sigmoid colon was traced using the assistance of the C‑arm according to the endoclips placed during colonoscopy. Bipolar
current was used to mark the edges of resection based on the C‑arm findings. The operative time was 110 minutes. On postoperative day 5,
the patient was discharged from the hospital after an uneventful postoperative stay. The combination of preoperative endoscopic clipping and
intraoperative C‑arm assistance can achieve accurate localization of tumors for laparoscopic surgery, potentially reducing operative time,
leading to resection with oncologically safe margins of the colon.

Keywords: C‑arm, endoscopic clipping, tumor localization

Introduction Case Report

When laparoscopic surgery is selected for gastrointestinal An 82‑year‑old man presented to our hospital with complaints
resection, accurate tumor localization is important. This of two episodes of bleeding per rectum mixed with stools.
knowledge may result in a prompt procedure and less There was no history of fever, abdominal pain, significant
blood loss.[1] Barium imaging, computed tomographic (CT) weight loss, or jaundice. On examination, he had grade 2
colonoscopy, intraoperative endoscopy, endoscopic tattooing, internal hemorrhoids. He was advised for a colonoscopy, which
and endoscopic clips are some of the techniques that have been showed a large sessile sigmoid colon polyp with irregular
developed to locate gastrointestinal lesions.[2‑6] Each of these surface [Figure 1] 28 cm from the anal verge with moderate
approaches have shortcomings. It is only possible to undergo a CT internal hemorrhoids. An endoscopic mucosal resection/
colonoscopy and barium imaging before surgery. Intraoperative endoscopic submucosal dissection was planned following this,
detection is only possible using a select few techniques, such as which showed a poor saline lifting sign [Figure 2], which was
intraoperative endoscopy, endoscopic tattooing, and endoscopic suggestive of deep submucosal infiltration.[10] Biopsy of the
clips. Technical issues can occasionally make tattooing
problematic, and it is linked to major side effects including Address for correspondence: Dr. Vishakha Kalikar,
perforation and inflammation.[7‑9] During open abdominal surgery, Plot No 425, 10th Road, Jai Ambe Nagar, Chembur, Mumbai ‑ 400 071,
Maharashtra, India.
normal endoscopic clips are felt; however, during laparoscopic E‑mail: [email protected]
surgery, they are neither palpable nor visible from outside the
walls of the intestine. We use a C‑arm intraoperatively in such
Received : 19‑Nov‑2023 Revised : 07‑Jan‑2024
cases where preoperative endoscopic clipping was done at the Accepted : 07‑Jan‑2024 Published Online : 04-Apr-2024
tumor site. It helps us easily locate the site of the tumor and
possibly decreases the operative time. This is an open access journal, and articles are distributed under the terms of the Creative
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How to cite this article: Bhandarkar S, Kalikar V, Ingle M, Patankar R.

DOI: A novel technique for intraoperative localization of colonic tumors during
10.4103/wjcs.wjcs_35_23 laparoscopic colectomy: A case report and review of the literature. World
J Colorectal Surg 2024;13:23-6.

© 2024 World Journal of Colorectal Surgery | Published by Wolters Kluwer - Medknow 23

 Bhandarkar, et al.: Novel technique for localizing colonic tumors

lesion was taken and Radiopaque Resolution™ Clips [Figures 3 mark the edges of resection based on the C‑arm findings.
and 4] were applied adjacent to the lesion at the proximal and Medial‑to‑lateral dissection was done around the marked
distal ends. The biopsy result showed moderately differentiated sigmoid colon along with the mesocolon. The right ureter and
adenocarcinoma in the colon. A CT scan of the abdomen was gonadal vessels were identified and safeguarded. Abdominal
performed, which showed a polypoidal lesion in the sigmoid incision was made at the left iliac fossa. A wound bag was
colon measuring 25 × 15 mm [Figures 5 and 6], with subtle placed to cover the incision and the dissected sigmoid colon
overlying prominence of the vasa recta. There was no evidence was removed from the incision and cut. Vascularity of the cut
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of fat stranding or adenopathy and no significant focal lesions ends was confirmed. The descending colon was anastomosed
were observed in the liver. After thorough routine preoperative with the rectum with end‑to‑end anastomosis using 3‑0
workup, the patient was planned for laparoscopic sigmoid Mersilk sutures in two layers. Hemostasis was confirmed. The
colectomy. abdominal drain was kept through the left paracolic gutter in
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The patient was positioned in the modified Lloyd Davies the pelvis, which was removed on postoperative day 5. The
position. Parts were prepared, painted, and draped. The operative time was 110 minutes. On postoperative day 5, the
following ports were placed: one 10‑mm port in the umbilical patient was discharged from the hospital after an uneventful
area, 10‑mm port in the right lumbar region and two 5‑mm postoperative stay.
ports in the left lumbar region, and one 5‑mm port in the upper
right lumbar region. Discussion
The growth over the sigmoid colon was traced using Since the COLOUR Study Group demonstrated that the
C‑arm assistance according to the endoclips placed during results of laparoscopic surgery for colorectal cancer were
colonoscopy [Figures 7-8]. Bipolar current was used to similar to those of traditional surgery in terms of survival

Figure 1: Endoscopic view of the lesion (green arrow) Figure 2: Failure of saline lift (yellow arrow)

Figure 3: Proximal end of the lesion Figure 4: Distal end of the lesion

24 World Journal of Colorectal Surgery ¦ Volume 13 ¦ Issue 1 ¦ January-March 2024

 Bhandarkar, et al.: Novel technique for localizing colonic tumors
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Figure 5: Axial view of ct abdomen Figure 6: Coronal view of ct abdomen

a b
Figure 8: (a) C‑arm images showing the proximal clip (blue arrow) and
the distal clip (yellow arrow), (b) C‑arm images showing the proximal
clip (blue arrow) and the distal clip (yellow arrow)

for localizing colorectal lesions using both conventional and

Figure 7: Intraoperative use of the C‑arm during the laparoscopic laparoscopic techniques.[13‑15]
procedure
Many types of dyes have been previously used such as
and recurrence, the frequency of laparoscopic and robotic methylene blue, indigo carmine, toludine blue, lymphazurine,
colorectal resections has increased.[11] As the colon cannot hemotoxylin, eosin, indocyanine green, and India ink.[16] India
be palpated during a minimally invasive laparoscopically ink is the most commonly used dye, which is known to cause
assisted colectomy, accurate preoperative localization is even inflammation.[17] Spot, a non‑India ink permanent marker, is a
more crucial to prevent the removal of the incorrect intestinal sterile suspension of highly purified and extremely fine carbon
segment.[12] For individuals with suspected colorectal disease, particles (GI Supply, Camp Hill, PA, United States). The use
colonoscopy has been considered to be the most effective of Spot in endoscopic tattooing has been approved by the US
Food and Drug Administration.
approach, particularly for locating and treating colonic polyps
or tumors. Colonoscopy can pinpoint lesions with accuracy, but The number of complications following endoscopic tattooing
it has logistical challenges and needs intraoperative availability. is relatively small but not limited, and most are related to
In addition, distention of the colon during colonoscopy makes transmural injection. The spillage rate of transmural injections
subsequent laparoscopic surgery difficult.[5] varies from 2.4% to 13%.[18] In addition, there are published
reports of focal peritonitis,[8,19] infected hematoma or abscess
Colonic tattooing with India ink is a reliable, cost‑effective
formation,[19‑21] inflammatory pseudotumor,[22] idiopathic
way to aid in intraoperative colonic lesion detection.[13,14] For
inflammatory bowel disease,[23] postoperative adhesions,[24]
a lesion that is obviously malignant, a colonoscopic tattoo
and tumor inoculation.[25]
injection can be done at the time of the first colonoscopy or
after a tumor is fully removed and shows signs of malignant Accurate localization of tumors during laparoscopic surgery
histology; colonoscopic tattoo injections can be performed is important. Finding the exact location of a tumor reduces
later on. During the laparoscopic procedure, the lesion may the surgery time, ultimately resulting in a shorter duration of
be observed by looking at the serosal surface’s staining in surgery, leading to a more precise resection of the affected
the affected area. Preoperative tattooing has been shown to intestine and quicker postoperative recovery, as well as a safer
be beneficial in more than 90% of the patients in prior trials oncological margin.[26]

World Journal of Colorectal Surgery ¦ Volume 13 ¦ Issue 1 ¦ January-March 2024 25

 Bhandarkar, et al.: Novel technique for localizing colonic tumors

The inability to view the clip from the serosal side of the 8. Singh S, Arif A, Fox C, Basnyat P. Complication after pre‑ operative
intestines is the primary disadvantage of endoscopic clipping.[27] India ink tattooing in a colonic lesion. Dig Surg 2006;23:303.
9. Del Rio P, Dell’Abate P. Complication of an endoscopic tattoo.
We hypothesized that this endoscopic clipping constraint may Endoscopy 2003;35:638.
be addressed by a reasonably simple, noninvasive method that 10. Matsuda T, Parra‑Blanco A, Saito Y, Sakamoto T, Nakajima T.
uses the help of a C‑arm for tumor location. Assessment of likelihood of submucosal invasion in non‑polypoid
colorectal neoplasms. Gastrointest Endos Clin N Am 2010;20:487‑96.
11. COLOR Study Group. COLOR: A randomized clinical trial
Conclusion
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comparing laparoscopic and open resection for colon cancer. Dig Surg
2000;17:617‑22.
The combination of preoperative endoscopic clipping
12. Wexner SD, Cohen SM, Ulrich A. Laparoscopic colorectal surgery—Are
and intraoperative C‑arm assistance can help achieve we being honest with our patients?. Dis Colon Rectum 1995;38:723‑7.
accurate localization of tumors for laparoscopic surgery, 13. Feingold DL, Addona T, Forde KA. Safety and reliability of tattooing
potentially reducing operative times, leading to resection with colorectal neoplasms prior to laparoscopic resection. J Gastrointest Surg
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oncologically safe margins of the colon. 2004;8:543‑6.

14. McArthur CS, Roayaie S, Waye JD. Safety of preoperation endoscopic
Declaration of patient consent tattoo with India ink for identification of colonic lesions. Surg Endosc
1999;13:397–400.
The authors certify that they have obtained all appropriate 15. Fu KI, Fujii T, Kato S. A new endoscopic tattooing technique for
patient consent forms. In the form, the patient(s) has/have identifying the location of colonic lesions during laparoscopic
given his/her/their consent for his/her/their images and other surgery: A comparison with the conventional technique. Endoscopy
clinical information to be reported in the journal. The patients 2001;33:687‑91.
16. Hammond DC, Lane FR, Welk RA, Madura MJ, Borreson DK,
understand that their names and initials will not be published
Passinault WJ, et al. Endoscopic tattooing of the colon. An experimental
and due efforts will be made to conceal their identity, but study. Am Surg 1989;55:457‑61.
anonymity cannot be guaranteed. 17. Kethu SR, Banerjee S, Desilets D, Diehl DL, Farraye FA, Kaul V, et al.
Endoscopic tattooing. Gastrointest Endosc 2010;72:681‑5.
Financial support and sponsorship 18. Trakarnsanga A, Akaraviputh T. Endoscopic tattooing of colorectal
Nil. lesions: Is it a risk‑free procedure? World J Gastrointest Endosc
2011;3:256‑60.
Conflicts of interest 19. Park SI, Genta RS, Romeo DP, Weesner RE. Colonic abscess and focal
There are no conflicts of interest. peritonitis secondary to india ink tattooing of the colon. Gastrointest
Endosc 1991;37:68‑71.
20. Marques I, Lagos AC, Pinto A, Neves BC. Rectal intramural hematoma:
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