Technique For Intraoperative Localization Research Articles

Transoral Robotic Surgery-Assisted Removal of Upper Aerodigestive Tract Foreign Bodies with Intraoperative Localization.

To describe the use of transoral robotic surgery (TORS) in conjunction with intraoperative localization techniques for removal of challenging upper aerodigestive tract (UADT) foreign bodies. Three cases were taken to the operating room for removal of UADT foreign bodies. Two of these cases had previously undergone failed surgery(s). TORS was performed in all 3 cases and intraoperative localization was used in 2 cases. All foreign bodies were successfully removed. This case series is the largest-to-date on UADT foreign body removals using TORS. Additionally, the novel use of intraoperative localization techniques in conjunction with TORS is described. Such an approach can facilitate the identification of difficult-to-identify foreign bodies, as well as potentially decreasing operative time, number of operations, and associated morbidity.

Intraoperative stimulation mapping of thalamocortical tracts in asleep and awake settings: novel electrophysiological, anatomical, and tractographic paradigms.

Despite the disabling deficits of motor apraxia and sensory ataxia resulting from intraoperative injury of the superior thalamocortical tracts (TCTs), region-specific electrophysiological localization is currently lacking. Herein, the authors describe a novel TCT mapping paradigm. Three patients, 1 asleep and 2 awake, underwent glioma resection affecting primarily the somatosensory cortex and underlying TCT. Stimulation was performed at the median, ulnar, and posterior tibial nerves. Parameters comprised single anodal pulses (duration 200-500 μsec, 2.1-4.7 Hz) with a current ranging from 10 to 25 mA. Recordings were captured with a bipolar stimulation probe, avoiding the classic collision technique. Positive localization sites were used to tractographically reconstruct the TCT in the third case. Employing one electrophysiological paradigm, the TCT was localized subcortically in all 3 cases by using a bipolar probe, peak range of 19.6-29.2 msec, trough of 23.3-34.8 msec, stimulation range of 10-25 mA. In the last case, tractographic reconstruction of the TCT validated a highly accurate TCT localization within a specific region of the posterior limb of the internal capsule. The authors describe the first electrophysiological technique for intraoperative localization and protection of the TCT in both asleep and awake craniotomies with tractographic validation, while avoiding the collision paradigm. None of the above paradigms have been previously reported. More data are required to further validate this technique.

Outcome of Pre-operative vs Intraoperative Localization Techniques in Insulinoma: Experience in a Tertiary Referral Center

Outcome of Pre-operative vs Intraoperative Localization Techniques in Insulinoma: Experience in a Tertiary Referral Center

Pre- and intraoperative thoracic spine localization techniques: a systematic review.

In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

A safe, reliable, inexpensive and novel technique to localize in the mid thoracic spine in the prone position: Proof of concept and technical illustration

Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip’s location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.

Challenges in the Diagnosis and Management of Cervical Endometriosis

Study Objective To discuss the evaluation and management of cervical endometriosis. To demonstrate a surgical technique for localization and excision. Design Case presentation and review of literature with narrated video footage. Setting A tertiary care hospital and endometriosis referral center. Patients or Participants Case Presentation. Interventions We present a case of cervical endometriosis, which includes: • Physical exam findings and tips for diagnosis • Preoperative imaging • A surgical technique for intraoperative localization and excision • Review of literature Measurements and Main Results N/A Conclusion In summary, cervical endometriosis is important to consider in the patients with abnormal bleeding and chronic pelvic pain. Imaging and consultation with subspecialists may be necessary. There exists no consensus guidelines, but complete excision is imperative when undergoing surgical management.

Pulmonary nodules precision localization techniques.

The advent of helical high-resolution CT scanners, the application of screening programs and the follow-up of patient with oncological history, led to an increasing number of diagnosis of small pulmonary nodule (less than 10 mm in maximum diameter), partially solid nodule or completely ground glass ones. Their management is controversial. Excisional biopsy by mean of video-assisted thoracic surgery is often a viable choice but to locate these lesions intraoperatively can be impossible without the aid of preoperative or intraoperative localization techniques. In this brief review we will analyze the benefit of adopting localization techniques prior to pulmonary resection for small pulmonary lesions and face the advantages and problems with the main techniques described in the literatures.

Is SNOLL a good localization technique in early breast cancer treatment? A single center's experience.

The aim of this study was to evaluate the method and present one center's experience in applying the SNOLL technique to patients with non-palpable suspicious breast lesions. 371 patients with suspected malignant lesions or diagnosed non-palpable breast cancer were subjected to a preoperative SNOLL procedure. The day before the surgery, they were administered two radiotracers to localize the tumor in the breast and the sentinel node. The following day, with the help of a handheld gamma probe the breast conserving surgery was performed. All 371 patients (100%) had their suspected occult breast lesions resected. Histo-pathological examination revealed cancer in 339 patients all these patients had their sentinel nodes examined. The intraoperative tests showed the sentinel node to be metastatic in 35 patients, who were then given a simultaneous axillary lymphadenectomy. Another 7 patients were diagnosed with positive lymph nodes in the final pathology and had to undergo a second operation. Reoperations compelled by positive surgical margins were performed in 26 cases. SNOLL as a good technique of intraoperative localization, enables to remove a nonpalpable breast cancer together with sentinel lymph node in a single surgical procedure. It seems to be a optional method to be used in patients treated with breast conserving therapy.

First Reported Use of Radiofrequency Identification (RFID) Technique for Targeted Excision of Suspicious Axillary Lymph Nodes in Early Stage Breast Cancer - Evaluation of Feasibility and Review of Current Recommendations.

The purpose of this study was to evaluate, whether radio frequency identification (RFID) labeling of axillary lymph nodes (LNs) for the use of targeted resection is feasible in primary breast cancer patients with suspicious LNs. We analyzed 10 consecutive patients where RFID technique was used for intraoperative detection of suspicious LNs without preceding neoadjuvant chemotherapy (NACT). We compared the specifics of these procedures to 10 consecutive sentinel lymph node biopsies (SLNB) in the cN0 situation. Intraoperative detection rate (DR) for the RFID-labeled target lymph node (TLN) was 100%. Perioperative complications were infrequent and comparable to SLNB. Average time for location of the RFID labeled TLN was quicker than for the SLN. In 71.4% the chip bearing TLN equaled a SLN. The use of the RFID technique for intraoperative localization of axillary LNs for targeted excision seems feasible. RFID technique for targeted axillary dissection (TAD) following NACT should be investigated in a prospective manner.

Intracorporeal direct measurement for localizing peripheral pulmonary nodules during thoracoscopy.

Localizing small lung nodules during thoracoscopy is challenging for thoracic surgeons. In this case series, a novel technique for intraoperative localization that combines preoperative computed tomography (CT) with direct measurement during thoracoscopy is described. A preoperative CT within two months before surgery was mandatory for precise planning of the resection area. During thoracoscopy, intracorporeal direct measurement (ICDM) for intraoperative localization was undergone if the targeted nodule was non-palpable and non-visualized. According to the location of the targeted nodule, longitudinal, and horizontal landmarks were chosen. The distances between the nodule and these landmarks were obtained from both CT images and intraoperative measurements during thoracoscopy. Based on the measurements, the x-axis and y-axis coordinates of the nodule were calculated and marked on the visceral pleura. A thoracoscopic wedge resection with an adequate margin was performed. From July 2014 to December 2018, ICDM was applied in 27 patients with peripheral pulmonary nodules smaller than 2 cm. Their medical records were reviewed retrospectively to evaluate the feasibility and safety of this technique. Twenty-six of the twenty-seven nodules were successfully identified (96.3%). The nodules included 13 primary lung cancers, 5 metastases, and 9 benign lesions. The median nodule size was 7 mm (range, 4-17 mm), and the median distance of the nodule from the visceral pleura was 8.1 mm (range, 1.0-31.2 mm). The median localization time was 24 minutes (range, 8-109 mm). Two patients (7.4%) had a prolonged air leak, but there was no procedure-related mortality. ICDM is an effective and safe method for localizing peripheral lung nodules during thoracoscopy.

Sentinel lymph node surgery in prostate cancer using magnetic particles.

Superparamagnetic iron oxide nanoparticles (SPIONs) are tested to identify sentinel lymph nodes (SLNs) to exploit the advantages of targeted pelvic SLN dissection (sPLND), while circumventing the disadvantages of established radioactive labeling. Here we review recent studies about sPLND in prostate cancer (PCa), including the first results of SLN detection using intraprostatic SPION-injection. A recent systematic literature review reveals that the diagnostic accuracy of sPLND is comparable with extended PLND (ePLND). sPLND combined with ePLND achieve better node removal by increasing the number of affected nodes. The first sentinel-based nomogram predicting lymph node invasion is established. A sentinel-nomogram update provides comparative predictions relative to ePLND models. sPLND using a magnetometer and SPIONs as a tracer is successful whenever applied to PCa, and SLN identification using MRI after intraprostatic injection of SPIONs is feasible. SLNs are present in an unexpectedly high number outside the ePLND template. SLN detection outside the ePLND template and the increased diagnostic value of sPLND compared with ePLND supports the individualized extension of PLND using sPLND in PCa. SPION-MRI, combined with a hand-held magnetometer, provides a nonradioactive technique for preoperative and intraoperative SLN localization. Further studies are required to evaluate the effects of sPLND on oncological outcomes.

MS 03.04 Technical Aspects of Limited Resection

Since its first report by Churchill and Belsey in 1939, and its evolution in lung cancer management described by Jensik in 1973 (Figure), pulmonary segmentectomy use for early lung cancer diagnosis and treatment has remained controversial. Definitive answers must wait regarding the results of the JCOG and Alliance randomized trials before true standards for surgical care for the lung cancer less than 2 cm are determined. Nevertheless, sublobar resections including wedge resection and segmentectomy are being adopted at an increasing rate compared to its use in previously published large databases (SEER, 5%; ACS NSQIP, 4%). Proper preoperative teaching and intraoperative performance of the technical aspects of sublobar resection are now becoming priorities for general thoracic resident and fellow training in an era where minimally invasive techniques are becoming increasingly the standard of care. General thoracic surgeons must have meticulous attention to detail in performing these resections in order to decrease the likelihood of collateral damage to neighboring segments as well as to minimize local recurrence whether there are performing the operation open, hybrid, standard VATS, uniportal VATS, or robotic. The technical aspects of sublobar resection begin before the patient goes to the operating room, and prime objectives in planning these resections include: 1) expertise in the segmental anatomy for that particular patient, 2) location and size of the nodule with relation to adjoining segmental bronchovascular components, 3) careful study and possible supplementation of high resolution computerized tomography with newer 3-D methods to define the spatial relationships of the nodule and segments, 4) pre- and intraoperative methods for locating the nodule if there is suspicion that parenchymal palpation will fail, 5) whether to perform wedge resection first or proceed directly to anatomic segmentectomy, 6) defining and managing the fissure between segments and recognizing when extended segmentectomy is possible or whether to convert to lobectomy and, 7) to use other intraoperative strategies to avoid technique related complications. Preoperative planning includes careful examination of the CT scan in the axial, coronal and sagittal plans in order to get a first appreciation of the depth, size, segmental anatomy and relationship of the nodule bronchovascular elements. Three-dimensional reconstruction can be as simple as navigational bronchoscopy planning images, or newer techniques for total 3-D pulmonary reconstruction which are in development.1 When there is a question of whether up front segmentectomy is to be performed and a part solid or non-solid nodule may not be palpable, intraoperative localization techniques such as navigation bronchoscopy2 or placement of fiducials/microcoils3 can be very useful. When there is no preoperative histologic diagnosis, whether a wedge or segmentectomy is performed initially will depend on the location and depth of the lesion as well as the fitness of the patient. Segmentectomy for initial diagnosis with intraoperative frozen section of both the primary lesion and suspicious level 13 and 14 stations can be prudent, especially if wedge resection could compromise performing the segmentectomy.4 In order to avoid positive margins, meticulous attention to detail with compulsive dissection and skeletonizing of the bronchovascular elements must be performed. If it is difficult to preserve the margin in a single segment resection, an extended resection of the parenchyma of adjacent segments or bisegmentectomy can be performed.5 There is controversy regarding the chance for loco-regional recurrence for segmentectomy especially in cases of pure solid lesions or segmentectomies which involve portions of the basilar segments or right upper lobe.6-8 Defining the fissure and the method with which it is divided can be one of the most important yet challenging portions of the operation. A variety of methods to define the fissure have evolved including inflation of the residual lung after segment occlusion, selective inflation of the segment to be removed, or the use of indocyanine green to define the intersegmental vein,4,5 and the fissure can be divided either with stapling alone or in combination with harmonic scalpel.9 A variety of fibrin sealants are available to decrease postoperative fistulae. With regard to the optimal approach, to date there have been no studies which show any superiority regarding conventional VATs or uniportal VATs for segmental resection, or any difference between the VATs approaches and robotic segmentectomy (10). A recent meta-analysis of over 7438 patients revealed a trend towards increased conversion to open with VATs, while postoperative complications, operation time, length of stay, chest tube duration, and number of lymph nodes were comparable.11

Diffusion-weighted imaging and diffusion tensor imaging in preoperative diagnostics

The extent of anisotropy and the direction of diffusion of H protons characterize the tissue structure and qualitative and quantitative evaluation of the appropriate parameters provide inferences for the membrane permeability, axon thickness, integrity and connectivity. The technique of fiber tracking is implemented in the presurgical diagnostics for lesions in the brain to show the relationship of the lesion to the fiber system. The benefit of this technique for preoperative and intraoperative localization of the pyramidal tracts, the primary motor areas, the optic radiation and the speech regions could be confirmed. In focal gliomas the fibers are often displaced to the edge of the tumor; however, in diffusely growing tumors the fiber system is infiltrated by tumor cells. In high-grade gliomas destruction of the fibers often occurs. Limitations are always present in brain regions where several fiber systems cross in different directions, such as the centrum semiovale. Appropriate neuroanatomical knowledge must be present in order to be able to immediately recognize such possible deviant pathways of the fiber tracking.

Current Concepts in the Presentation, Diagnosis and Management of Primary Hyperparathyroidism

Background: Primary hyperparathyroidism (PHPT) is a common clinical endocrine disorder. It is the most common cause of hypercalcemia in the outpatient setting. This review presents a brief summary of the new trends of presentation, diagnosis and management PHPT. Data Sources: PubMed (National Library of Medicine) articles, and Memorial Library archives of the University of Wisconsin System. Conclusions: PHPT occurs at any age, but it is most commonly seen in people over the age of 50 years and postmenopausal women. The current presentation of PHPT shifts from the classical symptomatic form to the asymptomatic form; however, parathyroidectomy is still the treatment of choice for both symptomatic and asymptomatic forms. In the past, bilateral neck exploration and intraoperative identification of all 4 parathyroid glands was the standard of treatment, nevertheless, nowadays, with the introduction of the preoperative and intraoperative localization techniques, the minimally invasive parathyroidectomy has evolved

Heading toward radioactive seed localization in non-palpable breast cancer surgery? A meta-analysis.

Wire-guided localization is the most commonly used technique for intraoperative localization of non-palpable breast cancer. Radioactive seed localization (RSL) is becoming more popular and seems to be a reliable alternative for intraoperative lesion localization. The purpose of the present meta-analysis was to evaluate the use of RSL. Primary study outcomes were irradicality and re-excision rates. In total 3168 patients were included. The clinical adaptation shows growing confidence in RSL and further growth is expected.

Margins: a status report from the Annual Meeting of the American Society of Breast Surgeons.

Since the emergence of breast conserving surgery (BCS) as an alternative to mastectomy in the 1980's, there has been little consensus on what constitutes acceptable margins for cases of invasive breast cancer, how best to evaluate margins in the operating room, or an understanding of the challenging process of margin assessment by pathologists. The program committee for the 15th Annual Meeting of The American Society of Breast Surgeons organized a plenary session to discuss the latest thinking and guidelines for these important issues. The SSO/ASTRO Consensus Guideline on Margins for BCS was an important focus of discussion. The SSO/ASTRO consensus panelists concluded that "no ink on tumor" is an adequate surgical margin for BCS in patients with invasive breast cancers. Intraoperative strategies to decrease the incidence of positive margins include intraoperative localization techniques (wire-localization, ultrasound, radioactive seed) and intraoperative margin assessments with specimen radiography, imprint cytology, and frozen section. Studies also demonstrate the positive effect of shave margins with or without intraoperative margin assessment. The College of American Pathologists protocols for breast specimen margin evaluation consider multiple variables that can impact the proper assessment of margins. These variables include: tissue fixation time, specimen orientation, cold ischemia time, leaking ink, specimen pancaking and others that surgeons need to be aware of. Determining when "enough is enough" should not only be the application of guidelines and national standards, but also a multidisciplinary discussion between breast cancer specialists for what is right for the individual patient's unique circumstances.

Ultrasound-guided excision combined with intraoperative assessment of gross macroscopic margins decreases the rate of reoperations for non-palpable invasive breast cancer

AimsThe standard technique for intraoperative tumour localization of clinically occult tumours is wire-guided localization (WGL). This, however, this has several disadvantages. The aim of the present work is to report our single-centre experience with intraoperative ultrasound-guided (IOUS) excision, performed by surgeons, combined with intraoperative assessment of macroscopic pathologic and ultrasound margins in non-palpable invasive cancers indicated for conservative breast therapy. Patients and methodsTwo-hundred and twenty-five non-palpable invasive breast cancers were subjected to excision with IOUS. The lesion was located in the operating room with a high-frequency ultrasound probe (8–12 MHz), which was then used to guide surgical removal. The specimen margins were estimated by ultrasonography and macroscopic pathologic examination. The sensitivity of IOUS and effectiveness in the characterization of the specimen margins were evaluated, assessing the need for reoperation. ResultsPathologic tumour size was 12.0 ± 6.7 mm and 13 lesions (6.4 %) were <5 mm. The sensitivity of IOUS localization was 99.6% (224/225 cases). Only one cancer of less than 5 mm was not localized. The average weight of the specimens was 26.1 g. A second operation was required to remove margins in the 4% of cases (9/225). In 5 cases remains of in situ or invasive carcinoma were found. In two cases, conservative surgery was converted to mastectomy. ConclusionsIOUS excision combined with the intraoperative assessment of the macroscopic margins of non-palpable breast cancers is a safe, useful, and efficient technique. We obtained an excellent characterization of tumour margins with moderate removal of breast tissue and consequently a lower number of reoperations were required and good cosmetic results were obtained. We believe that use of this technique in conservative breast cancer surgery should be recommended.

Endoscopic ultrasound-guided gold fiducial marker placement for intraoperative identification of insulinoma

Insulinomas are the most common functioning pancreatic neuroendocrine neoplasm, comprising 30%–45% of these tumors. Although laparoscopic resection is safe, minimally invasive, and is associated with shorter length of hospital stay, tumor localization at surgery can be challenging. We describe endoscopic ultrasound (EUS)-guided fiducial placement as a new technique for intraoperative localization of pancreatic insulinoma. A 36-year-old woman with episodes of confusion that resolved with intake of glucose and whose laboratory tests were suggestive of insulinoma was referred for laparoscopic distal pancreatectomy. Linear-array EUS (GF-UCT 240; Olympus Corp., Center Valley, Pennsylvania, USA) confirmed a tail mass (Fig.1). After retracting the stylet of the fine-needle aspiration (FNA) needle (Expect 19-gauge Flex needle; Boston Scientific Corp., Natick, Massachusetts, USA) by 2cm, one gold fiducial (3 × 0.8mm; Best Medical International, Springfield, Virginia, USA) was back-loaded into the lumen of the needle and sealed with bone wax. At EUS, the fiducials were deployed within the tumor by advancing the stylet forward (Fig.2). Overall, two fiducials were deployed (Fig.3), and a preoperative computed tomography (CT) scan confirmed their position. At laparoscopy, the fiducials were identified using cross-table fluoroscopy (Fig.4), and distal pancreatectomy with splenectomy was performed. A frozen section confirmed negative tumor margins, and the explant specimen revealed the tumor with fiducials in place (Fig.5). Final pathological analysis revealed T1 N0 grade II pancreatic neuroendocrine neoplasm (Fig.6). Fig.1 Linear-array endoscopic ultrasound (EUS) image of the isoechoic mass lesion in the tail of pancreas, superior to the left kidney. Fig.2 Fluoroscopic image showing the linear-array echoendoscope with the 19-gauge fine-needle aspiration (FNA) needle and the first fiducial. Fig.3 Endoscopic ultrasound (EUS) image showing the markers within the lesion casting an acoustic shadow (arrow). Fig.4 Intraoperative fluoroscopic image with the stapler gun in place. The two fiducial markers can be easily visualized. Fig.5 Postoperative specimen of the pancreas, showing the fiducial marker within the lesion. Fig.6 Postoperative histological specimen showing uniform sheets of polyhedral cells with hyperchromatic nuclei and abundant eosinophilic cytoplasm, consistent with a neuroendocrine neoplasm (hematoxylin and eosin stain, ×40). Preoperative injection of India ink [1] or indocyanine green [2] under EUS guidance was developed to facilitate quick tumor localization and to decrease operative time and blood transfusion requirements [3]. However, the disadvantages of dyes include peritonitis, infection, allergic reactions, and reabsorption within tissue planes [4]. In this report, we have described the use of fiducials as an alternative technique for this indication. The fiducials are inexpensive ($80 for five fiducials), easy to deploy, can be identified readily using fluoroscopy or intraoperative ultrasound, and (unlike dyes) do not extravasate into surrounding tissue. Endoscopy_UCTN_Code_TTT_1AS_2AD

Systematic review of intravenous methylene blue in parathyroid surgery

Methylene blue is an intraoperative adjunct for localization of enlarged parathyroid glands. The availability of preoperative and other intraoperative localization methods, and the reported adverse effects of methylene blue make its routine use debatable. The aim of this study was to perform a systematic review of the use of methylene blue in parathyroidectomy. A systematic review of English-language literature in MEDLINE and Scopus databases on the use of intravenous methylene blue in parathyroid surgery was carried out. There were no randomized clinical trials. Thirty-nine observational studies were identified, of which 33 did not have a control arm. The overall median staining rate for abnormal parathyroid glands was 100 per cent. The median cure rates in the methylene blue and no-methylene blue arms were 100 and 98 per cent respectively. Neurotoxicity was reported in 25 patients, all of whom were taking serotonergic medication. Observational evidence suggests that methylene blue is efficacious in identifying enlarged parathyroid glands. Toxicity appears to be mild in the absence of concomitant use of serotonin reuptake inhibitors. The effectiveness of methylene blue in the context of currently used preoperative and intraoperative localization techniques has yet to be shown.

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing. Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2-3 ml of autologous blood was injected into the gastric muscle layer at 3-4 cm proximal to the lesion during endoscopy. The study subjects consisted of 15 males and 8 females with a mean age of 61 ± 10.4 years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3 ± 2.7 cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.). Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.