Laparoscopic Janeway Permanent Gastrostomy
A permanent gastrostomy may be appropriate for patients who have no prospect of being able to feed themselves orally. The laparoscopic approach to a gastrostomy may allow for the advantages of decreased pain, hospital stay, and convolescent period in patients who usually have significant comorbidities already.
Preoperative Preparation and Operating Room Setup
Patients should have sequential compression stockings and subcutaneous heparin or low-molecular-weight heparin should be considered perioperatively. Prophylactic antibiotics are give 30 min prior to incision. A foley catheter can be placed and a nasogastric tube to decompress the stomach is recommended.
The patient is placed in the supine position. The surgeon stands on the patient’s left and the assistant on the right. Dual monitors should be positioned at the head of the bed. A basic laparoscopic tray including straight and/or angled laparoscopes, atraumatic graspers, and dissectors should be present, as well as a basic open procedural tray.
Port Placement
The initial trocar is placed in a infraumbilical position either with an open cut-down technique, an optical trocar, or pre-insufflation with a Veress needle followed by trocar placement, optical or not. A survey of the abdomen can assess the abdominal wall for any adhesions that may obstruct safe port placement. Two 5 mm ports are placed lateral to the midclavicular lines on the left and right, between 15 and 20 cm from the costal margins, usually above the umbilicus. A 12 mm trocar is placed at a site appropriate to wear the greater curvature of the stomach is grasped and easily brought up to the abdominal wall for eventual externalization.
Creation of Gastric Diverticulum
Through the 12 mm port, a 60 mm endoscopic stapler is used to create a gastric diverticulum along the greater curvature
Maturation of Gastric Diverticulum and Placement of Gastrostomy Tube
An atraumatic grasper is used to grasp the diverticulum and externalize it through the 12 mm port site. Care should be taken to assure there is no tension on the diverticulum as it approaches the skin. The end of the diverticulum is opened with an energy device and the edges approximated to the skin with interrupted 3-0 vicryl or other absorbable suture. A balloon-tipped gastrostomy tube or foley catheter of at least 24 Fr diameter is placed into the gastric lumen and the balloon inflated and secured to the abdominal wall.
Ports are removed under direct visualization after final survey of the abdomen for bleeding or injury, and skin incisions closed with sutures or surgical glue. Any 12 mm trocar sites should be closed at the fascial level.
Postoperative Care
Feedings can be started within 24 hours of the permanent gastrostomy creation. Care should be taken to secure the gastrostomy carefully, and to flush it frequently with water to avoid clogging.
References
1. Duh QY, Senokozlieff AL, Choe YS, Siperstein AE, Rowland K, Way LW. Laparoscopic gastrostomy and jejunostomy. Arch Surg. 1999;134:151-156.
2. Wu J, Soper NJ, Gastrostomy and jejunostomy. In: Jones DB, Wu J, Soper NJ, eds. Laparoscpoic Surgery: Principles and Practice. New York: Marcel Dekker;2004:219-241.
