Laparoscopic Gastrostomy

Timothy M. Farrell, MD and Mark J. Koruda, MD

lthough percutaneous endoscopic gastrostomy (PEG), Indications

A ,ariginally reported in 1980,1 is' an excellent method
for providing long-term gastric decompression or access
for enteral feeding, occasionally upper abdominal adhe-
sions or oropharyngeal obstruction mandate an operative
approach. Laparoscopic gastrostomy allows placement of
a larger tube than can be achieved by radiologically guided
percutaneous gastrostomy, and provides a more effective
seal between the stomach and the anterior abdominal wall.
Patients with certain aerodigestive tumors, severe esoph-
ageal strictures, or wired mandibles from fractures are not
candidates for upper endoscopy and thus cannot be man-
aged by PEG. Alternatively, those patients with history of
upper abdominal surgery or trauma may not be candi-
dates for percutaneous gastrostomy because of concern
for adhesions.

From the Department of Surgery, University of North Carolina, Chapel Hill,

NC.
Address reprint requests to Timothy M. Farrell, MD Campus Box 7210, UNC
Department of Surgery, Chapel Hill, NC 27599.
Copyright 9 2001 by W.B. Saunders Company
1524-153X/01/0304-0008535.00/0
doi:10.1053/ot~T~.2001.27787

258 Operative Techniques in General Surgery, Vol 3, No 4 (December), 2001: pp 258-262

Laparoscopic Gastrostomy 259

SURGICAL TECHNIQUE

rrocar and grasper

n gastrostomy
;ite

3ites of "T" fasteners

it skin level
solid dots)

Sites of "T" fast~

on anterior stom
(open dots)
.aparoscope, insufflation
:amers and trocar
n umbilicus

1 These methods have been described previously by other authors. 2-4 After appropriate
general or local anesthesia, 5 and with a urinary bladder catheter and nasogastric tube in
place, abdominal access is achieved by either the direct-puncture or open technique.
Pneumoperitoneum is established to 15 mm Hg with carbon dioxide gas. An umbilical
trocar is placed for an angled operative laparoscope (5 mm). A full exploration is performed
and the stomach is visualized. Placing the patient in reverse Trendelenburg position helps
facilitate this exploration. A second port is placed in the left upper abdomen for manipula-
tion of the stomach and eventual placement of the gastrostomy tube. An appropriate site is
selected along the anterior greater curve, and the gastric wall is elevated to the ventral
abdominal wall to estimate the site of tube entry.
260 Farrell and Koruda

"T" fasteners

die

~mach

Live

2 The pneumoperitoneum is then decreased to 8 mm Hg, and the stomach is

insufflated with air via the nasogastric tube. A commercially available percu-
taneous delivery system (FLEXIFLO Lap G laparoscopic gastrostomy kit (Ross
Products Columbus, OH) with Brown/Mueller T-fasteners) is used. T-fasteners
are placed circumferentially in four quadrants, first through the skin around
the left upper quadrant incision and then around the intended gastrostomy site.
Once intraluminal, traction is applied by the T-fasteners. The left abdominal
trocar is removed, and an 18-gauge needle is inserted through the same inci-
sion and into the stomach between the gastric sutures.

er

,j
O

3 Using the Seldinger technique, a guidewire is introduced through

the needle into the gastric lumen.
Laparoscopic Gastrostomy 261

Guidewire

Introducer with peel-away

"~" "~ ' J sheath

4 Successively increasing dilators are introduced, followed by a dilator with

tear-away sheath.

Balloon tipped G-tu

between "T" fastenc
stomach

5 An 18-French flexible gastrostomy tube with a distal balloon is directed

through the sheath into the stomach. The balloon is inflated, and as the
pneumoperitoneum is released the stay sutures are gathered up and tied over
bolsters externally, thereby maintaining the greater curvature's apposition to
the ventral abdominal walt. The umbilical trocar is removed, and the wound
is closed with absorbable suture.
262
Postoperative Care
The gastrostomy tube is left to gravity drainage until evi-
dence of normal gastric emptying is apparent. The tube is
flushed as necessary to maintain patency. Sutures are left
in place for 3 weeks, after which time the tube may be
safely changed as an outpatient.
Outcomes
Mean operative times range between 20.5 and 39 min-
utes. 6'7 Mortality is exceedingly low, and complication
rates range from 8% to 18.3%. Complications include
leakage, bleeding, wound infection, failed placement, and
loss of tube function. 6'&9 In one retrospective series, lapa-
roscopic gastrostomy was less likely to result in compli-
cations than open gastrostomy (18.3% vs. 24.9%), and
was similar to PEG (17.1%). l~
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FarreU and Koruda
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