Case of the month: December 2020 - getting inked

About this case study

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Case synopsis

A middle-aged patient underwent a colonoscopy for change in bowel habit and altered blood in his stool. A lesion suspicious for cancer was identified in the ascending colon and biopsies were taken. Two tattoos were placed distal to the lesion and a staging CT scan was arranged. The scan did not identify the lesion in question and showed no evidence of spread. Biopsies revealed a cancer.  

The patient’s case was discussed in the local multidisciplinary team (MDT) meeting and they were listed for a laparoscopic right hemicolectomy. On the day of his their operation, all notes, scans and MDT discussions were reviewed by the operating surgeon and her the team. The endoscopy report read ‘2 tattoos placed distal to lesion in ascending colon’. Only photos of the lesion were seen. The report commented on poor bowel preparation limiting some views. 

Following laparoscope insertion, a detailed examination of the bowel did not show any evidence of a tattoo. The operation proceeded and a right hemicolectomy was performed to include the area described in the endoscopy report, as per the MDT plan.

Given the lack of tattoo, the surgical consultant and assisting trainee examined the resected colon and could not identify any evidence of the malignant lesion. An on-table colonoscopy was performed which identified the cancer in the distal transverse colon, just proximal to the splenic flexure. No tattoos were evident and this area was further tattooed.

The operation was converted to an open laparotomy and resection was extended to include the lesion. This led to a greater operative and bowel-handling time than originally planned.

Safety incidents and contributory factors

Below is a visual representation of this case. We have highlighted the incidents involved and their contributory factors:



This case highlights the importance of endoscopic lesion localisation in the operative patient pathway. Here are some learning points to consider:

Lesion localisation

• Lesion mis-localisation at colonoscopy isn’t uncommon and has consequences on subsequent surgical management.  
• Adjuncts such as magnetic imaging enhancers and pre-endoscopy cross-sectional imaging decrease the likelihood of lesion mis-localisation.
• Bowel preparation may hinder accurate lesion identification and localisation and areas of concern may need to be reassessed through position change or repeat procedures.

Tattoo practice

In this case, tattooing practice at index colonoscopy may have been suboptimal. We’ve outlined some steps that may be helpful:


When to tattoo

  • Tattooing guides surgical resection and endoscopic surveillance strategies.
  • Tattooing should be done for lesions > 20mm or suspected malignancy (outside of caecum and rectum). 
  • Don’t tattoo in the rectum – this can cause staining of the mesorectum and impact significantly on surgical management.


How to tattoo


  • A potential reason for invisible tattoos is superficial delivery. 
  • It is widespread practice now to raise a saline bleb before switching to tattoo – this ensures the tattoo is placed in the submucosal space (ie not too superficial or deep).



  • Generally, tattooing 2-5cm distal to a lesion is acceptable.
  • Tattooing can be performed immediately distal to a lesion margin to aid specific localisation. However, it may be sensible to places tattoos further away to prevent tumour cell seeding[6]
  • For lesions that can be endoscopically resected, this also limits the risk of submucosal fibrosis or muscle injury during subsequent resection.


How to report tattooing 

When reporting tattooing, the following should be documented:

  • The exact tattoo location should be stated relative to the lesion, including the distance from the lesion.
  • The exact number of tattoos placed.

If more than one set of tattoos, explicit description of relative location to any lesions should be documented.


Monitoring tattooing practice 

  • Ideally services should have a tattoo policy and audit practice regularly.

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