Laparoscopic Gastrostomy

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Diana Leigh Diesen
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Placement of a gastrostomy tube for feeding is one of the most common pediatric surgery procedures. The options for feeding tube placement into the stomach include an open gastrostomy tube placement, a laparoscopic gastrostomy tube placement, a percutaneous endoscopic gastrostomy (PEG), and a laparoscopic-assisted PEG placement. The choice of procedures depends on patient characteristics, anatomic considerations, and surgeon preference. An open Stamm gastrostomy involves a laparotomy and securing the stomach to the anterior abdominal wall with four sutures after having secured the feeding tube to the stomach with purse-string sutures. A PEG involves placing a feeding tube through the skin and into the stomach with the assistance of endoscopic intraluminal visualization of the stomach. It does not require a laparotomy, but also does not allow visualization of the tract or the peritoneal space while the feeding tube is being placed. PEG placement also does not provide suture fixation of the stomach to the anterior abdominal wall. Laparoscopic assisted gastrostomy tube placement provides visualization of the feeding tube and track as well as optional suture fixation of the stomach to the anterior abdominal wall.

Indications

Gastrostomy tubes are placed in children who have feeding difficulties, failure to thrive, or intestinal dysfunction. These patients may have other conditions that may necessitate further workup. If patients for example have significant gastroesophageal reflux disease (GERD), they may need to be further evaluated for medical verses surgical management of reflux. Patients with failure to thrive undergo an extensive workup preoperatively to elucidate the etiology of their failure to thrive. Those patients with concomitant medical issues also need optimization of chronic and any acute conditions prior to surgical feeding tube placement. The use of routine UGI prior to gastrostomy tube placement has not been demonstrated to be cost effective due to the low incidence of malrotation in the general population. It may be beneficial in subgroups of patients at high risk or with appropriate symptoms.

Operative Management

Placement of laparoscopic gastrostomy tubes requires general anesthesia. Contraindications to laparoscopic gastrostomy tube placement include those who cannot tolerate pneumoperitoneum (severe pulmonary or cardiac disease), active skin infection, acute illness, or suboptimal treatment of chronic illness as this is not an emergent or urgent procedure. Children who are acutely ill or not optimally managed should receive nutrition via a NG or OG tube until their medical conditions are optimized. Those with previous abdominal surgeries may have adhesions requiring further dissection and have an increased incidence of conversion to open procedures.

The patient is positioned supine on the operating table. General endotracheal anesthesia is performed by anesthesia. Hemodynamic monitoring is placed a necessary. The monitors are placed above the patient’s head. The patient is prepped and draped. An appropriate Gastrostomy tube exit site is chosen and marked. This is ideally sufficient distant from the costal margin and midline. A location should be chosen in which no undue tension will be placed on the stomach once the procedure is completed. This is confirmed with direct laparoscopic visualization.

An incision is made in the umbilicus and a 3-5mm port in placed. Insufflation is begun with a pressure of 8-12mm Hg. A 30-degree camera is placed. The port tip is positioned just past the fascia to ensure enough working space in the abdomen. The premarked gastrostomy tube site is then incised with a knife. A locking grasper is placed under direct visualization at the premarked location in the left upper quadrant where the gastrostomy tube is to exit. A 5mm port may alternatively be placed in this location and then a grasper placed through the port. If further dissection is necessary, for example if patient has adhesions from previous surgeries, another 3mm stab incision may be made in the right upper quadrant or for further dissection/retraction. The stomach is insufflated with air. An appropriate place on the stomach is selected as the gastrostomy tube site, usually two thirds from the gastroesophageal junction to the pylorus. Care should be taken to ensure that the gastrostomy tube is not too close to the pylorus as the balloon on the tube can case pyloric obstruction. One should avoid injury to the gastroepiploic vessels as well. The location of the gastrostomy tube should be chosen so that it does not place undo tension on the stomach when the procedure is completed.

The stomach is grasped with the locking grasper in the location where the gastrostomy tube is to be placed. Two securing sutures are then placed which will secure the stomach to the anterior abdominal wall. The gastrostomy tube will then be placed between these two sutures. The grasper should hold the stomach where you want the gastrostomy tube to be placed. Use an 11 blade and create a small 1-2mm incision where the stitch is to be placed (approximately 1cm from the gastrostomy tube exit). A vicryl suture on a large needle (CT-1 for infants) is then passed through the abdominal wall taking 1 cm of gastric wall and then passed back through the abdominal wall. The exit site is ~1cm from the entrance. The suture is then passed from the exit site through the subcutaneous tissue to the entrance site of the stitch. Another stitch is then placed on the other side of the locking grasper, one centimeter from the exit of the gastrostomy tube. This stitch should also go through the abdominal wall taking 1m of gastric wall and then pass back through the abdominal wall. This stitch is then also passed from the exit site through the subcutaneous tissue to the entrance site of the stitch. These stitches should be ~1.5cm apart. If placed too far apart, it can be difficult to provide tension on the stomach when placing the needle, wire, and dilators. If too close, it may be difficult to place the gastrostomy tube.

The grasper is then removed and the dilator set is used to place the gastrostomy tube. A needle is placed thought the track where the grasper had been. The needle is then placed into the stomach between the sutures, again ensuring that there will not be undo tension on the stomach once the case is completed (and pneumoperitoneum evacuated). The wire is then placed through the needle under direct visualization to ensure the wire is in the stomach and not in the peritoneum. The wire should slide easily. If it does not, it may be in the stomach wall.  Remove the needle and hold onto the wire. Place the serial dilators over the wire in a Slinger-like fashion. Dilate up to 20mm. Place the 8mm dilator through the gastrostomy tube. Remove the largest dilator and then place the gastrostomy tube with the 8mm dilator onto the wire through the tract and into the stomach under direct visualization. Inflate the balloon with 2-5ml of sterile water. Remove the dilator and the wire. Connect the tubing to the gastrostomy tube. Flush the tubing with water and aspirate gastric contents. Ensure the tube is working properly and is visually in position. Tie the 2 stitches that were previously placed ensuring that the stomach is well approximated to the anterior abdominal wall – secure but not ischemic. Make sure the knot of the stitch is buried in the 1-2mm incision that had been created. These incisions can be closed with dermabond.

After the gastrostomy tube is in place, remove the umbilical port and desufflate the abdomen. Close the umbilical port. Connect the gastrostomy tube to the drainage tube that comes with the kit to allow for decompression of the stomach. Secure in place with a dressing.

There are other ways to place laparoscopic gastrostomy tubes. Some authors advocate the use of T fasteners that are placed through the skin and fascia and into the stomach. The fastener is then deployed in the stomach and the suture is pulled to the so that the bumper lies snuggly against the anterior abdominal wall. Do not secure too tightly or necrosis may occur. Do not secure too loosely or the stomach will not oppose the anterior abdominal wall. Multiple T-fasteners are used to secure the stomach. This approach is often preferable in the larger patient as it is more difficult to get a stitch through the abdominal wall and stomach of these larger patients. The T fasteners are then removed by cutting the suture after 2-20 days depending of the surgeon’s preferences.

Other groups advocate the placement of nonabsorable U stitches that are placed through the skin, fascia, through the stomach and then out again. The stitch is then tied around the exterior edge of the gastrostomy tube. These sutures may be removed after 2-3 days.

Postoperative Care

Depending on the patient’s condition, the gastrostomy tube may be used shortly after surgery. Others prefer to leave gastrostomy tube to gravity for 24 hours and then slowly restarting feeds. This feeding regime is at the discretion of the surgeon.

The gastrostomy tube may be secured with a dressing. Depending on surgeon preference the dressing may be left in place 24 hr- 2weeks. Simple soap and water is all that is needed for cleaning. The wound should be monitored for granulation tissue. If excess granulation tissue develops, silver nitrate may be applied. If excess granulation tissue leads to leakage and is not responsive to silver nitrate, excision may be needed.

The gastrostomy tube may be exchanged once reliable adherence of the stomach to the abdominal wall has occurred 4-8 weeks after placement depending on the patient’s condition and surgeon preference.

Once a gastrostomy tube is no longer needed, it may be removed in the clinic by aspirating the fluid from the balloon and removing the tubing. The tract will usually close within a few days.

Complications

A potential complication of gastrostomy tube placement includes early gastrostomy tube removal or displacement. If dislodged in the first few weeks, the gastrostomy tube may be replaced in a similar fashion to the way it was inserted. Other complications include bleeding, infection, damage to nearby structures, injury to the posterior stomach wall, need for revision, intra-abdominal leakage, herniation of omentum, local stoma problems, intraperitoneal placement, and chronic gastrocutaneous fistula after removal.

References

Antonoff MB. Hess DJ. Saltzman DA. Acton RD. Modified approach to laparoscopic gastrostomy tube placement minimizes complications. Ped Sug Int 2009 Apr; 25(4): 349-53.

Gauderer M. Gastrostomy. Operative Pediatric Surgery. 7th edition. Ed. Spitz & Coran. 2013.

Petrosyan M, Hunter C, Estrada J, Guner Y, Qureshi F, Stein J, Ford HR, Wang K, Nguyen N. Subcutaneous fixation of gastrostomy tube is superior to temporary fixation. J Laparoendosc Adv Surg Tech A. 2010 Mar; 20(2):207-9.

Tirabassi M & Georgeson KE. Laparoscopic Gastrostomy. Atlas of Pediatric Laparoscopy and Thoracoscopy. 2008

Villalona GA. MCKee MA. Diefenback KA. Modified laparoscopic gastrostomy technique reduces gastrostomy tract dehiscence. J Laparoendosc Adv Surg Tech A 2011 May; 21(4) 355-9.