Endoscopic Tattooing FAQs: The Bleb Method Explained

Endoscopic Tattooing FAQs: The Bleb Method Explained

When applying endoscopic tattoos, there are two widely used tattooing techniques, that are considered by most physicians as the most reliable methods — saline bleb and direct.

In a previous post we gave an overview of both endoscopic tattoo methods. In this post we’re taking a deeper dive and providing a closer look at the preferred method — the bleb technique.

What is the Bleb Method?

In this preferred method, blebs of saline (1 mL each) are first injected into the submucosa of the bowel (If tattooing for surgical localization inject the saline in four quadrants, circumferentially). The tattoo is then injected (0.5 to 0.75 mL) into each of the blebs. This allows for a more certain injection of the tattoo into the submucosa.

Whether a bleb or direct method is used, an effective endoscopic tattoo always requires:

  • Careful insertion of the needle into the submucosal plane at a 30-45° angle.
  • A closely monitored and controlled injection to avoid accidental injection into the peritoneal cavity and diffuse intra abdominal staining, which can be potentially misleading during surgery.1
  • Inject the tattoo 2-3 cm distal to the lesion (do not inject directly into the lesion).

Why is the Bleb Method Preferred?

This multi-step approach allows doctors and nurses to more reliably inject the tattoo in the proper spot (the submucosa), avoid transmural injection, and optimize localization during surgery.2

Why Tattooing Matters

Dark and permanent tattoos are effective tools to enable identification and expedite localization for both surgical localization and clinical surveillance at follow-up colonoscopy. For surgical localization, tattooing has proven to both decrease time spent in the operating room3 and greatly improve tumor localization.4 Tattooing is also a recommended practice in society guidelines and most recently in the ESGE’s Guidelines for EMR and Polypectomy.5 Endoscopic Tattooing benefits many stakeholders who are are fighting colon cancer, has dedicated reimbursement, and it only takes a few minutes to mark. Don’t forget to take the last step in a polypectomy or surgical referral, don’t forget to tattoo.

Have more questions about the bleb method or endoscopic tattooing? In “A Gastroenterologist’s Guide to Endoscopic Tattooing Methods” you’ll find answers to some of the most frequently asked questions about endoscopic tattooing, get a closer look at the most common methods for tattooing, and learn more about this latest tool in the fight against colon cancer. Get your copy here:

Get The Guide

Learn how to tattoo using the bleb method here with a demonstration from Dr. Rex:

1 – Rex DK. Driving patient safety with endoscopic tattooing. Gastroenterology and Endoscopy News. 2015 May.

2 –  16 Hyman N, Waye JD. Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery. Gastrointest Endosc 1991;37:56-8.

3 – Arteaga-Gonzalez I, et. al., The use of preoperative endoscopic tattooing in laparoscopic colorectal cancer surgery for endoscopically advanced tumors: a prospective comparative clinical study. World J Surg. 2006. 30(4):605–611.

4 –  Askin MP, Waye JD, Fiedler L, Harpaz N. Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound. Gastrointestinal Endoscopy. 2002;56(3):339-342. doi:10.1067/mge.2002.126905.

5 –  Ferlitsch M, Moss A, Hassan C, etal. Colorectal polypectomy and endoscopic mucosal resection (EMR): ESGE Clinical Guideline. 2017.