Inadvertent tattooing of adjacent large bowel: a case report and review of literature

INTRODUCTION

Marking of colonic lesions which require surgical resection prior to surgery is of extreme importance, especially since laparoscopic approach is becoming increasingly common in colonic resections. Endoscopic tattooing of lesions, using dyes such as India ink, is recommended in such cases¹, and is currently the most commonly used marking technique. This procedure was found to be both effective and safe in several studies.^2 , 3

Several side effects and complications of India ink tattooing have been reported. Among them are localized leakages of ink into the peritoneal cavity, which were mostly asymptomatic³, and transmural injection of India ink into adjacent structures, such as small bowel⁴ and rectus muscle.⁵ However, we were not able to find any reports describing transmural injection of India ink into adjacent segments of large bowel, which prompted us to submit our case.

We present the case of a patient who underwent endoscopic tattooing of a colonic lesion prior to surgery. At laparotomy we noticed that the India ink was injected through the colon wall into an adjacent segment of large bowel, thus leading to inaccurate marking of the lesion.

CASE REPORT

A 75 year old woman, with a history of hypothyroidism and essential hypertension, underwent a screening colonoscopy for the first time in her life. It is worth noting that the patient was asymptomatic. Colonoscopy revealed two polyps which were deemed endoscopically unresectable: one at the cecum and one at 40 cm from the anus. Both were biopsied, and a marking with India ink was made distal to the lesion at 40 cm in order to easily locate it at surgery. Both biopsies showed tubulovillous adenoma with areas of high grade dysplasia.