Laparoscopic-Assisted Gastrostomy
Tim Strate, Oliver Mann
Introduction
Laparoscopic gastrostomy is an excellent minimally invasive procedure for patients who are unable to swallow and unable to undergo percutaneous endoscopic
gastrostomy. The original open method was devised as a feeding tube by Bronislaw Kader in 1896 and modified for minimally invasive technique in the 1990s.
Indications and Contraindications
Indications
■See chapter “Conventional Gastrostomy: Temporary or Permanent Gastric Fistula.”
Contraindications
■Ascites
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Previous gastric or major upper abdominal surgery (in this case at least laparoscopic exploration might be feasible)
Preoperative Investigation/Preparation for the Procedure
See chapter “Surgical Gastrostomy: Temporary or Permanent Gastric Fistula.”
Procedure Access
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3-Trocar technique (2¥10-mm and 1¥5-mm trocars)
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10-mm subumbilical trocar
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Pneumoperitoneum of 12mmHg
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10-mm trocar in left lower quadrant
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5-mm trocar in right upper quadrant
STEP 1 Exposure
Exposure and exploration, adhesiolysis if necessary.
STEP 2 Three full-thickness stitches
Using a straight needle which is brought into the abdomen through the skin at the left
hypogastric region, a triangle is created by three full-thickness stitches which allow the
catheter system to be introduced under laparoscopic control (stitches: skin-abdominal
wall-stomach-abdominal wall-skin).
STEP 3 Insertion of the guidewire
A 1-cm stab incision is made in the center of the triangle created by the three sutures which are held under tension. Under laparoscopic vision the anterior stomach wall is punctured by an 18-gauge needle exactly in the center of the triangle. Through the needle a guidewire is inserted into the stomach and a 26-Fr. dilatator with a peel-away sheath is pushed over the guidewire into the stomach percutaneously.
At the end of the procedure the correct placement of the tube is confirmed
radiographically.
STEP 4 Introducing the catheter system
The inner dilatator is removed and a regular 24-Fr. urinary catheter is placed through the remaining peel-away sheath into the stomach. The peel-away sheath is removed.
After the balloon of the catheter is inflated, the stomach is pulled against the abdominal wall and the sutures are subcutaneously secured under traction and progressive reduc- tion of the pneumoperitoneum. The catheter is then put under traction for 24h.
See chapter “Conventional Gastrostomy: Temporary or Permanent Gastric Fistula” for
postoperative investigations and complications.
Tricks of the Senior Surgeon
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Exchange the 24-Fr. urinary catheter for a special gastrostomy button device 14days postoperatively (see Figure).
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To avoid dietary deficiencies, patients should be under the supervision of a nutritional specialist.
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