How can I write a colonoscopy report for an adult patient with a known colonic lesion scheduled for surgical resection, who had endoscopic tattooing for lesion localization, including past abdominal surgeries, anticoagulation therapy, diabetes mellitus, and cardiovascular disease?

Colonoscopy Report for Endoscopic Tattooing Prior to Surgical Resection

For a patient undergoing endoscopic tattooing to mark a colonic lesion before planned surgical resection, your report must document the tattoo material, exact placement location relative to the lesion, injection technique, number of sites, volume per site, and photographic evidence—all critical for surgical localization and patient safety. 1

Essential Pre-Procedure Documentation

• Indication for tattooing: State that the tattoo is being placed to facilitate intraoperative localization of the lesion during planned surgical resection. 1

• Patient comorbidities: Document relevant history including prior abdominal surgeries (which may alter anatomy), anticoagulation therapy status (affects bleeding risk), diabetes mellitus (may influence wound healing), and cardiovascular disease (relevant for perioperative risk stratification). 1

• Bowel preparation quality: Record preparation adequacy using a validated scale such as the Boston Bowel Preparation Scale, as this affects visualization and tattoo placement accuracy. 1

Intra-Procedure Technical Documentation

Lesion Characteristics

• Precise anatomical location: Document the exact location using anatomic landmarks (e.g., "sigmoid colon, 25 cm from anal verge" or "descending colon at splenic flexure"). 1

• Lesion size and morphology: Record dimensions and appearance of the lesion being marked. 1

• Distance from landmarks: Note proximity to the ileocecal valve, flexures, or rectum. 1

Tattoo Injection Technique

Use the saline-bleb safety technique to prevent complications: First inject normal saline (0.5–1.0 mL) through a 22–25 gauge needle to create a submucosal bleb, confirming correct submucosal placement and preventing dangerous transmural injection. 1, 2

• Tattooing agent: Specify "sterile carbon particle suspension" (e.g., SPOT®) as the material used—this is the standard of care. 1

• Volume per injection site: Inject 0.75–1.0 mL of carbon suspension at each tattoo site after confirming submucosal placement with saline. 1

Critical Placement Strategy for Surgical Cases

For surgical resection, place tattoos both in line with the lesion AND on the opposite colonic wall to maximize intraoperative visibility from multiple angles during laparoscopic or open surgery. 3, 1

• Number and distribution: Place 2–3 separate tattoo sites circumferentially around the colon (e.g., at 3,6, and 9 o'clock positions relative to the lesion). 1, 3

• Distance from lesion: Position tattoos at least 3 cm (30 mm) distal to the lesion to avoid submucosal fibrosis that could complicate surgical resection margins or future endoscopic intervention. 1, 3

• Avoid proximal or perilesional placement: Tattooing at or immediately adjacent to the lesion induces fibrosis that increases surgical difficulty and perforation risk. 1

Exceptions Where Tattooing Is Unnecessary

• Cecum and ileocecal valve: Tattoos are not required for lesions in the cecum or adjacent to the ileocecal valve, as these are clear anatomic landmarks. 1, 3

• Low rectum: Lesions within 5 cm of the anal verge do not require tattooing due to obvious anatomic localization. 1, 3

• Alternative documentation: For these locations, capture photographic images showing the lesion with the anatomic landmark clearly visible. 1

Photographic Documentation Requirements

• Tattoo visualization: Obtain and archive images showing each tattoo site in relation to the lesion, using both standard white-light and close-up views. 1

• Spatial relationship: Capture images that clearly demonstrate the distance and clock-face position of tattoos relative to the lesion. 1

• Post-injection appearance: Document the submucosal bleb appearance immediately after injection to confirm proper placement. 1

Safety and Complications Documentation

• Immediate assessment: Inspect the injection sites for evidence of transmural injection (serosal staining visible through the mucosa suggests peritoneal spillage). 2, 4

• Patient tolerance: Record that the patient tolerated the tattooing procedure without immediate complications. 5

• Absence of adverse events: Note specifically that no peritonitis, abscess formation, or significant bleeding occurred. 2, 4

Post-Procedure Instructions and Follow-Up

• Written discharge information: Provide the patient with written instructions about potential delayed complications (abdominal pain, fever) that could indicate localized peritonitis from tattoo injection, along with an emergency contact number. 1

• Anticoagulation management: For patients on anticoagulation or antiplatelet therapy, document the individualized plan for medication resumption, balancing thromboembolism risk against post-procedure bleeding risk, ideally determined in consultation with the prescribing specialist before the procedure. 1

• Surgical coordination: Communicate tattoo details directly to the surgical team, including exact placement locations and photographic documentation. 1

Report Structure and Standardization

Your institution should establish a written standard protocol for tattoo placement that all endoscopists and surgeons follow consistently. 1, 3

Sample Documentation Template

Indication: Endoscopic tattooing for preoperative localization of [lesion description] scheduled for surgical resection.

Technique: After confirming submucosal placement with saline injection, sterile carbon particle suspension was injected using a 23-gauge needle.

Tattoo placement: Three tattoos placed at 3,6, and 9 o'clock positions, 3 cm distal to the lesion at [anatomic location]. Total volume 1.0 mL per site.

Complications: None. No evidence of transmural injection or peritoneal spillage.

Photographic documentation: Images [reference image numbers] show tattoo locations relative to lesion.

Communication: Tattoo location details and images provided to surgical team for operative planning.

Common Pitfalls to Avoid

• Tattooing too close to the lesion: This is the most common error and causes submucosal fibrosis that complicates surgery. Always maintain at least 3 cm distance. 1, 3

• Transmural injection: Failure to confirm submucosal placement before injecting carbon suspension can cause localized peritonitis or abscess formation. Always use the saline-bleb technique first. 1, 2, 4

• Insufficient volume: Injecting less than 0.75 mL per site may result in tattoos that are not visible intraoperatively. 1

• Single tattoo site: Placing only one tattoo reduces intraoperative visibility, especially during laparoscopic surgery where visualization angles are limited. 3, 6

• Inadequate documentation: Failing to specify exact tattoo locations relative to the lesion creates confusion for the surgical team and may compromise localization. 1