Black Macular Patches on Parietal Peritoneum and Other Extraintestinal Sites from Intraperitoneal Spillage and Spread of India Ink from Preoperative Endoscopic Tattooing: An Endoscopic, Surgical, Gross Pathologic, and Microscopic Study

Abstract

Endoscopic injection of India ink using standard sclerotherapy needles can inadvertently tattoo extraintestinal sites in addition to tattooing the primary lesion. Despite its striking appearance, this intraoperative, gross, and microscopic finding is likely not pathologically significant, given its proposed pathophysiology. Surgical recognition of this entity is important, however, to prevent misinterpretation of findings as peritoneal melanoma, endometrial implants, infarcted mesentery, or tattooed cancer. This complication may be prevented by proper tattooing technique.

Peritoneal “melanosis”

“…In the presented case we were not able to determine the nature of the pigment, but some possible causes of black tissue deposits were excluded including melanosis from anthraquinone-containing laxatives, melanin from metastatic melanoma, iron deposits from iron ingestion, charcoal from charcoal ingestion, tissue necrosis and intraperitoneal spillage and spread of India ink from preoperative endoscopic tattooing [16]. Probably the term peritoneal pigmentation would be a more appropriate term for our case as well as for similar cases, where the nature of the pigment is not known.…”

“…These finding is not of pathological significance. A helpful clue to the proper diagnosis is location of pigmentation, which can be detected at both injection and extraintestinal sites [16].…”

A novel endoscopic fluorescent band ligation method for tumor localization

“…Moreover, this method can prolong operation time and exposure to general anesthesia [9]. Endoscopic tattooing is the most frequently used method, although endoscopic tattooing with India ink has been associated with several complications, including severe adhesion and difficulties in tumor localization due to leakage, peritonitis, and bulky granuloma, making laparoscopic surgery more difficult [10][11][12]. Tattooing materials containing charcoal such as India ink or SPOT Ò (GI Supply, Camp Hill, PA) cannot be used in Korea because they are not approved by the Korea Ministry of Food and Drug Safety (FDA).…”

Complications of Colonoscopy

“…It has been reported cases of intramural hematoma, colonic abscess, rectus muscle abscess following colonoscopic tattooing, bowel obstruction, retroperitoneal colonic perforation due to localized necrosis, adhesion ileus, and spread of the dye following colonoscopic tattooing [68][69][70][71][72][73][74][75].…”