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Durable enteral access is a commonly performed operation in pediatric surgery practice today. Methods for gastrostomy include open, percutaneous, endoscopic, and laparoscopic techniques. Laparoscopic gastrostomy in children offers many advantages over the open approach, including excellent visual exposure, improved cosmesis, and reduced pain. Compared to percutaneous endoscopic insertion, laparoscopic gastrostomy allows for secure fixation of the stomach to the abdominal wall, direct visualization of the tube/button position through the abdominal wall and into the stomach, and the ability to complete concurrent procedures, including fundoplication. Earlier initiation and tolerance of feeds, and reduced length of stay with potential same-day discharge, are additional advantages of the laparoscopic or laparoscopic-assisted approach.
Indications for Workup and Operation
In patients with functional gastrointestinal tracts, enteral nutrition is preferable over parenteral nutrition as it is more physiologic, minimizes costs, and avoids the complications of central venous access. Creation of a gastrostomy is indicated if oral nutrition is inadequate (suboptimal caloric intake) or not feasible (swallowing dysfunction) for a prolonged period of time, leading to failure to thrive and grow. Unique feeding requirements secondary to metabolic disorders are another increasingly common indication for enteral access. A concomitant history of gastroesophageal (GE) reflux disease should prompt consideration for concurrent fundoplication. Uncontrolled ascites, coagulopathy, and gastric pathology (e.g., microgastria) are relative contraindications to gastrostomy.
Patients are positioned supine on the operating room (OR) table with their arms at their sides and general anesthesia is induced. For infants, they can be placed at the foot of the OR table. Preoperative antibiotics are begun as the patient is appropriately secured and padded. The surgeon can be positioned on the patient’s left or right or at the foot of the bed, depending on surgeon preference, with the screen located at the head of the bed ( Fig. 4-1 ). The gastrostomy exit site is marked at a minimum of one finger’s breadth below the left costal margin before insufflation ( Fig. 4-2 ). Depending on age and comorbidities, especially cardiac, insufflation pressures up to 12 to 15 mm Hg can be used.
Laparoscopic Percutaneous Technique
The current standard laparoscopic gastrostomy technique was conceptualized and described by Georgeson. A vertical midline incision through the umbilicus is created and a 5-mm cannula is inserted. After the pneumoperitoneum is established, a small stab incision is made in the previously marked left upper quadrant for insertion of a locking grasper. The anesthesiologist is asked to insufflate the stomach through an orogastric tube to help prevent placing the subsequent U-sutures through the back wall of the stomach ( Fig. 4-3A ). The stomach is grasped along the greater curvature directly across from the incisura or about two-thirds of the distance from the GE junction to the pylorus, taking care to avoid injuring the gastroepiploic vessels ( Fig. 4-3B ). This site provides ample distance from the pylorus to prevent obstruction from the button and to allow for sufficient fundal tissue to be available for a future fundoplication if warranted.
The stomach is delivered up to the anterior abdominal wall. Two transabdominal monofilament U-sutures are placed on either side of the chosen gastrostomy site ( Fig. 4-4 ): size 2-0 with SH needle in neonates with thin abdominal walls; 0 in most other infants; and 1 or 2 in older children or patients with thick abdominal walls on a large needle, which may need to be snared by an Endoclose device (Covidien, Mansfield, MA). These monofilament sutures are passed through the anterior abdominal wall, through at least 1 cm of the stomach, and back out the abdominal wall and skin. These two sutures will create a “narrow hammock” for introduction of the gastrostomy button utilizing the Seldinger technique. Once the U-sutures are placed, the grasper is removed and a stoma measuring device is inserted to determine the appropriate stem length for the gastrostomy button. With the stomach on traction, a needle is introduced through the center of the “narrow hammock,” and withdrawal of air or collapse of the distended stomach should be noted on needle entry into the gastric lumen ( Fig. 4-5 ). A J-tipped guidewire is introduced through the needle into the stomach. The needle is removed, and the gastrostomy site and stomach are sequentially dilated to 18 Fr over the wire using a Cook dilator set (Cook Inc., Bloomington, IN). A 20 Fr dilator or spreading of hemostat can be used to dilate the abdominal wall, but not the stomach. An 8 Fr dilator is inserted into the chosen gastrostomy button for insertion over the guidewire into the stomach ( Fig. 4-6 ). The balloon is then inflated slowly under visualization to ensure its position within the stomach. The wire and dilator are then withdrawn ( Fig. 4-7 ).