**2. Endoscopy prior to laparoscopy**

### **2.1 Tattooing prior to laparoscopic resection**

Accurate localization of the surgical site is crucial prior to laparoscopic resection. Flat colorectal polyps or cancer are often hard to localize by visualization of the colonic wall or even by palpation. Measuring the distance of the lesion from the anal verge or correlating with a barium enema is usually not accurate enough for localizing the segment prior to colonic resection. Intra-operative colonoscopy is accurate in localizing the lesions, but it might interfere with patient positioning or laparoscopic field by air insufflation; in addition to prolonging the procedure time looking for the lesion.

Endoscopic tattooing of the lesion prior to laparoscopic resection has proven to be accurate and efficient. Feingold et al in a retrospective study of 50 patients who underwent endoscopic tattooing prior to laparoscopic resection found that 88% of these lesions were accurately localized during the laparoscopic procedure; no complications were reported.[1] Many agents have been studied for use in endoscopic tattooing. Methylene blue and indigo carmine can successfully stain the serosa. However, these agents disappear in few days, making it not suitable for endoscopic tattooing. [2,3] Indian ink, however, can stain the serosa for years making it the ideal agent for tattooing [4]. Indian ink should be sterilized and diluted prior to injection [5]. A prepackaged sterilized and already diluted Indian ink, SPOT® (GI Supply, Camp Hill, Pennsylvania, USA) is currently used by many endoscopists for endoscopic tattooing [6]. It is recommended to inject the tattoo in 3 circumferential sites distal to lesion in case one of these sites is on the mesenteric side of the colon [4] The longterm safety of Indian ink was evaluated in a study of 55 patients; no clinical complications such as fever, infection or abdominal pain were reported. There was mild chronic inflammation at the site of injection in 6 patients without clinical significance[7]. Intraperitoneal spillage of Indian ink can happen and it is usually without clinical

Role of Endoscopy in Laparoscopic Procedures

without any complications[17]. In another trial from Germany that included 23 patients, LMCP was successful in 17 patients [18]. In all previously mentioned trials, there was

Laparoscopic wedge resection is currently the standard of care for the removal of gastric submucosal tumor and in particular Gastrointestinal Stromal Tumor (GIST). Laparoscopic wedge resection is more feasible in tumors located at the anterior wall of the stomach Tumors located in the posterior wall of the stomach or the gastro-esophageal junctions were traditionally managed by surgery to ensure negative margins and to avoid excessive gastric resection. Endoscopy assisted laparoscopic wedge resection was successfully performed in gastric submucosal tumors located in the above mentioned area to spare open surgery. In this technique, endoscopy is used simultaneously during laparoscopy to localize the tumor and ensure negative margins. In a trial of 18 patients, this technique was proven successful with a single complication (perforation) in one case [19]. A new technique described by Hiki et al utilizes endoscopic submucosal dissection (ESD) of three–fourths of the circumference around the submucosal tumor followed by seromuscular dissection of the exact threefourths of the circumference by laparoscopy then the tumor is removed by a laparoscopic stapling device [20]. This technique is successful regardless of the tumor location and the

minimal to no discomfort from the laparoscopic part of the procedure.

initial ESD done by endoscopy to ensure the exact margins of the tumor.

with air insufflations and water irrigation [22].

**3.5 Laparoscopy assisted foreign body removal** 

time and minimal bleeding [25].

**3.3 Combined colonoscopy and laparoscopy to close colonic perforation** 

**3.4 Combined laparoscopic-endoscopic approach for duodenal lesions** 

Iatrogenic colonic perforation can be treated with segmental laparoscopic resection or with laparoscopic suturing [21]. A new technique was proposed to close iatrogenic colonic perforation with combined endoscopy and laparoscopy approach. This technique involves mucosal closure using endoscopic clips, serosal closure using laparoscopy and a leak test

Endoscopic mucosal resection and endoscopic mucosal dissection of duodenal lesions is feasible [23]. However, it is complicated with higher rates of bleeding, perforation and tumor recurrence compared to EMR and ESD of colonic and stomach lesions [24]. Sakon et al described a new technique utilizing ESD of the margins of the duodenal lesion followed by laparoscopic resection. This promising technique was associated with less procedure

Most of ingested foreign body can be removed endoscopically. In few instances, sharp foreign body can invade through the gastrointestinal wall to other organ and require surgical assistance. Lanitis et al described a case in which a patient ingested two sharp needles, one of them migrated to the liver and another one invaded into the abdominal wall. Combined endoscopy and laparoscopy technique was successful in removing both lesions [26]. Another case report described the removal of large dental bridge by the combined approach. The foreign body was snared by the endoscopy in the stomach but it could not pass through the overtube in the esophagus. Gastrostomy was done using laparoscope then the snared foreign body was delivered to a laparoscopy grasper through the gastrostomy

**3.2 Endoscopy assisted laparoscopic wedge resection** 

239

significance. There are a few case reports of peritonitis or peritoneal abscess as a result of intraperitoneal spillage [8].

Preoperative endoscopic tattooing of pancreatic lesions prior to laparoscopic distal pancreatectomy has been recently reported [9]. This technique utilizes endoscopic ultrasound with the use of a fine needle for tattooing under endoscopic guidance. In a study of 36 patients who underwent laparoscopic distal pancreatictomy, 10 patients had preoperative endoscopic tattooing. Patients in the preoperative tattooing group had shorter operation times compared to the control group [10]. Figure 1 Illustrate tattooing of duodenal lesion prior to laparoscopic removal.
