Laparoscopic percutaneous gastrostomy

Abstract

In patients unable to swallow for a prolonged period of time, a gastrostomy has been considered a preferred feeding route. The percutaneous endoscopic technique, as originated by Gauderer et al.,1Gauderer M Ponsky J Izant Jr, R Gastrostomy without laparotomy.J Pediatr Surg. 1990; 15: 872-875Abstract Full Text PDF Scopus (1748) Google Scholar has been in use for more than a dozen years. The technique requires that the endoscope's light be clearly seen transilluminating the anterior abdominal wall. This location should be free of any scar tissue or any visible vascular structures. The procedure should not be performed unless the endoscopist sees a well-defined impression of an assistant's finger tip when light pressure is applied to the anterior abdominal wall. The most important step of the entire procedure is the careful selection of the site for the gastrostomy tube. Recently, we encountered two patients in whom selection site was difficult because of previous surgeries with scar tissue and in one case because of various abdominal wall hernias. We used a laparoscopic percutaneous endoscopic technique in order to be able to find an appropriate site in the stomach where a Seldinger needle could be placed through the abdominal wall directly through the stomach. The first case was an 82-year-old woman with a large ventral hernia in the abdominal wall that did not allow the usual PEG to be placed. She was brought to the operating room, under general anesthesia, where a 1 cm infra-umbilical incision was made. The Hasson cannula was introduced with the abdominal cavity insufflated. Numerous dense intra-abdominal adhesions were lysed by use of blunt and sharp dissection. Following this, the endoscope was introduced. The stomach could not readily be identified. Further blunt dissection had to be done to identify the stomach. Following this, the gastrostomy tube was placed percutaneously in the standard technique under direct vision, via the laparoscope. A Seldinger needle could be seen piercing the stomach wall appropriately. Following this, an 18-gauge wire was placed through the needle into the stomach and grasped by an endoscope snare. The rest of the procedure preceded in the usual fashion. The second case was a 75-year-old man with a subdural hematoma whose neurologic impairment required feeding access. Because the stomach could never be transilluminated through the anterior abdominal wall, he was taken to the operating room and while he was under general anesthesia a Hasson cannula was inserted at the umbilical area through a 2 cm incision, air insufflating the intra-abdominal cavity. At that point, the endoscope was passed and the stomach was well visualized. At this point, a Seldinger needle was passed through the left upper quadrant area to puncture the stomach anteriorly near the greater curvature. The guide wire was passed through the needle, which was grasped by the endoscopist and pulled out the oral end. The percutaneous endoscopic gastrostomy tube was threaded over the guide wire and pulled out the anterior abdominal wall under direct vision. After this, the outer bar was inserted over the PEG tube to hold it in position against the anterior abdominal wall. The Hasson cannula was removed. Our technique offers an alternative to laparotomy and gastrostomy when the usual PEG technique cannot be done. Our technique has certain similarities to a laparoscopic percutaneous gastrostomy technique described by Shallman.2Shallmann R Laparoscopic percutaneous gastrostomy.Gastrointest Endosc. 1991; 4: 493-494Abstract Full Text PDF Scopus (17) Google Scholar In Shallman's technique, a laparoscope was used to deliver sutures through the abdominal wall to draw the stomach up near the abdominal wall so that a needle could be placed percutaneously into the stomach followed by a technique for placing a percutaneous gastrostomy tube. In that particular case, a Foley catheter was used. Fig. 2Stomach opposed to anterior abdominal wall at the end of procedure.View Large Image Figure ViewerDownload (PPT) In our technique, once access into the stomach is obtained with the needle and the guide wire, the technique proceeds endoscopically without sutures. We do believe our technique will facilitate feeding gastrostomy tubes in patients in whom the usual technique cannot be done. It will serve as an alternative to laparotomy.