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INDICATIONS

Placement of a gastrostomy tube is indicated for feeding or prolonged gastric decompression. The laparoscopic approach is indicated when a percutaneous endoscopic gastrostomy (PEG) cannot be placed or is contraindicated. This includes situations such as an obstructing oropharyngeal or esophageal lesion, or when interposition of the colon or omentum over the stomach makes the blind percutaneous approach unsafe. Patients with prior upper abdominal surgery may have adhesions that would render a laparoscopic approach difficult. Such patients may require placement of the gastrostomy tube under direct visualization using open techniques.

Patients who require gastrostomy tube placement are often debilitated and malnourished, and the laparoscopic approach is particularly advantageous for this population.

PREOPERATIVE PREPARATION

If enteric feeding is only needed for a short interval, placement of a nasoenteric tube should be considered as an alternative. Distal obstruction, delayed gastric emptying, and gastroesophageal reflux are contraindications to gastric feeding. In patients with a risk of aspiration, placement of a jejunal feeding tube may be warranted.

ANESTHESIA

General anesthesia with endotracheal intubation is necessary for this operation. Complete neuromuscular blockade is required. Nausea control with ondansetron and a second agent is beneficial. If there has been little bleeding during the dissection, ketorolac is given at the completion of the procedure to diminish postoperative pain.

POSITION

The patient is positioned on a spit-leg bed with arms tucked at the sides. The surgeon stands between the patient’s legs, and the assistant stands to the left side of the patient. The operative monitor is placed above the patient’s head (Figure 1). A Foley catheter and orogastric tube are placed after the induction of anesthesia. The abdomen of the patient from the nipple lines to the pubis is shaved with clippers after induction of anesthesia, and the abdomen is sterilely prepped.

DETAILS OF PROCEDURE

Trocar Position

The operation commences with insufflation of the abdomen using the Veress needle technique at the umbilicus. Alternatively, initial access can be achieved using the Hasson technique at the umbilicus.

The procedure is performed with a two-trocar technique. The proposed site of the gastrostomy is marked on the skin, at least two fingerbreadths below the left costal margin. A 5-mm (or 10-mm) cannula for a 5-mm (or 10-mm) laparoscope is placed at the umbilicus. Depending on the size of the patient and distance to the stomach, the camera port may need to be placed more cephalad along the midline. In a small patient a 5-mm laparoscope is adequate, but in a large patient a 10-mm scope may be necessary for adequate imaging. A 5-mm port is placed in the right subcostal region at the midclavicular line. An additional 5-mm ...

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