Journal of Minimal Access Surgery

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Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 438--440

Indocyanine green tattooing for resection of endophytic submucosal lesions at anatomically difficult locations: Broader application of robotic platform

Akshay Pratap, Benedetto Mungo, Martin McCarter 
 Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA

Correspondence Address:
Dr. Akshay Pratap
Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado


Background: Endophytic submucosal masses at anatomically difficult locations such as lesser curve of the stomach, juxta-gastroesophageal junction and duodenum are challenging to resect laparoscopically due to proximity of vital structures and difficulty to visualise them. To overcome these limitations, we describe a technique of endoscopic tattooing with indocyanine green (ICG) injection into the lesion allowing easy identification and oncological resection in a minimally invasive manner. Patients and Methods: The technique of endoscopic tattooing of the lesion and robotic transgastric eversion resection technique is described in patients with gastrointestinal tumours at difficult anatomical location. Results: Gastric gastrointestinal stromal tumours at the lesser curve (n = 3) and gastroesophageal junction (n = 1) were resected using this technique successfully. Conclusion: The use of intraoperative ICG tattooing of endophytic submucosal lesions at difficult locations can facilitate minimally invasive oncologic resection. This technique allows the surgeon to be more comfortable to approach complex lesions safely to improve patient outcomes.

How to cite this article:
Pratap A, Mungo B, McCarter M. Indocyanine green tattooing for resection of endophytic submucosal lesions at anatomically difficult locations: Broader application of robotic platform.J Min Access Surg 2020;16:438-440

How to cite this URL:
Pratap A, Mungo B, McCarter M. Indocyanine green tattooing for resection of endophytic submucosal lesions at anatomically difficult locations: Broader application of robotic platform. J Min Access Surg [serial online] 2020 [cited 2020 Nov 30 ];16:438-440
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Gastrointestinal stromal tumour (GIST) is the most common mesenchymal tumour in the gastrointestinal tract.[1] Mutations in the cell surface KIT receptor of interstitial cells of Cajal is found in approximately 90% of cases.[2] GISTs >2 cm should be resected with negative margins because of their malignant potential.[3] GISTs arising at anatomically difficult locations such as lesser curve and gastroesophageal junction comprise approximately 5% but are technically challenging due to their endophytic growth making them inconspicuous with minimally invasive techniques. Moreover, the surgeon may inadvertently remove a large amount of mucosa and create stenosis if the resection is not well planned. The recent introduction of da Vinci XI platform with its firefly technology has taken minimally invasive surgery to the next level advancement with excellent visualisation and safe oncologic resection of gastrointestinal cancers. We describe our technique of indocyanine green (ICG) tattooing of endophytic GISTs located at the lesser curve and para-gastroesophageal junction to facilitate a focused transgastric oncologic resection of the lesions.

 Patients and Methods

The operative technique of four patients with biopsy-proven GIST is described in this report. Their workup consisted of an upper endoscopy with core biopsy, an endoscopic ultrasound and computed tomography [Figure 1]a and [Figure 1]b. All lesions were >3 cm and were located at the lesser curve (n = 3) and 2 cm distal to the gastroesophageal junction (n = 1). Operative position and port placement are shown in [Figure 1]c. The patient is placed in a supine position. A three-port technique is used with 8-mm robotic trocars, with a port camera 12 cm below the xiphoid process and two 8-mm robotic ports. An additional left upper assist port can be selectively placed. Next, an intraoperative endoscopy is performed after the console surgeon gently occludes the pylorus to prevent insufflation of the small bowel during endoscopy. The location of the lesion with reference to the gastroesophageal junction is carefully delineated and measured [Figure 1]d. Once the lesion is identified, under direct vision 3 cc (1.5 mg) of ICG is injected at four quadrants in the submucosal plane, as shown in [Figure 1]e. Next, the surgeon turns on the firefly mode and can accurately localise the lesion as a green fluorescent region of interest [Figure 1]f. A gastrotomy is made right over the fluorescent signal to prevent excessive mucosal resection which may result in gastric stenosis [Figure 1]g. The lesion can then be easily everted and resected with gross negative margins using robotic endoshears [Figure 1]h. A specimen is retrieved and the gastrotomy is closed in two layers using inner absorbable and an outer non-absorbable 3-0 suture [Figure 1]i. A leak test with endoscopic insufflation is performed at the completion of the procedure.{Figure 1}


Of the four patients who underwent resection, three were male and one was female, with a mean age of 65.3 years (range: 56–72 years). The mean operative time was 110 min (range: 75–145 min). There were no conversions or intraoperative complications. Patients were discharged on post-operative day 1 on full liquids. At a mean follow-up of 6 months, none of the patients showed evidence of stenosis of the stenosis or reflux symptoms.


Minimally invasive organ-sparing surgery has become a paradigm for most GISTs in favourable locations such as the anterior wall and greater curvature of the stomach.[4] However, this approach is very challenging in difficult anatomic locations with regard to limited visualisation and dexterity of conventional laparoscopy platforms. Robotic-assisted surgery has gained popularity in allowing surgeons to perform oncological resections with confidence, dexterity and high definition three-dimensional image.[5] Of great significance in a robotic platform is the availability of photodynamic eye filter commonly called the firefly technology. The firefly technology uses near-infrared imaging to detect an injected tracer dye of ICG in the blood. Although most robotic surgeons utilise the firefly to evaluate blood flow characteristics of the organ of interest,[6],[7] we envisioned that ICG tattooing could be very useful to visualise deep-seated lesions at anatomically difficult locations. In our limited series of gastric GISTs at unfavourable locations, we were able to safely tattoo the lesion, identify it using firefly imaging and perform a limited oncologic resection. Besides the known benefits of robotic minimally invasive surgery – including smaller incisions, less blood loss, less post-operative pain, shorter hospital stays and earlier returns to work – the addition of intraoperative tattooing of unfavourably located submucosal lesion using the firefly system can improve patient outcomes even further and allow surgeons to approach these lesions in a safe manner.


The technique of intraoperative tattooing with ICG on a robotic platform is attractive to safely resect endophytic lesions at complex locations. Ease of topographic location using green fluorescence facilitates accurate planning of resection line for either eversion resection or wedge resection adhering to oncological principles at the same time offering benefits of minimally invasive surgery to the patients.

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Conflicts of interest

There are no conflicts of interest.


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