(1)
Royal Hospital for Sick Children, Edinburgh, Scotland, UK
Abstract
The laparoscopic approach offers several potential advantages; including good visualisation, no need for further surgical procedures and cosmesis.
Keywords
Button Gastrostomy, Laparoscopy16.1 General Information
The laparoscopic approach offers several potential advantages:
Good visualisation of the stomach, to avoid colonic spearing and enable correct placement within the gastric body.
Avoidance of the need for a secondary procedure associated with traditional gastrostomy tubes, eliminating the serious complication of gastric separation and peritonitis.
Early cosmetic advantage associated with the button rather than the larger percutaneous endoscopic gastrostomy (PEG) tube.
16.2 Working Instruments
5-mm Hassan port
30° telescope
Atraumatic grasper (3 or 5 mm, depending on size of child)
AMT PEG Assist™ Initial Placement Gastrostomy Kit (Applied Medical Technology; Brecksville, OH, USA)
Or
Cook endovascular dilators, sizes 6 Fr to 18 Fr (Cook Medical, Bloomington, IN, USA)
18G needle
Floppy-tip guide wire, diameter 0.035 or 0.038 in.
11 blade scalpel
Also
1–0 or 0 vicryl or polydioxanone suture (PDS) on a MO45 round-body needle
Gastrostomy button (MIC-KEY low profile size 12–14) (Kimberley-Clark; Roswell, GA, USA)
16.3 Positioning
Patient is placed supine on the operating table. The surgeon stands at the end of the table for small infants, or to the right of larger children. The camera person is on the left. The patient requires a nasogastric (NG) tube.
Before preparation of the abdomen, the costal margin on both sides should be marked out.
16.4 Surgical Technique
- 1.
Infraumbilical 5-mm port is inserted using the Hassan cut down technique.
- 2.
Pneumoperitoneum is established, with typical pressure settings 5–10 mmHg, depending on the size and weight of the child.
- 3.
The stomach is identified.
- 4.
A small, 2-mm incision is made through the abdominal wall under direct vision with the 11 blade scalpel over the gastric area where you wish the button to sit, ensuring that there is enough space between the costal margin and the button for comfort when the pneumoperitoneum is released. Insert the atraumatic grasper directly though the incision without port placement (Fig. 16.1).
- 5.
Identify the pylorus, antrum, and body of the stomach and decide on the best siting of the gastrostomy. Grasp this area of the stomach and bring it up to the anterior abdominal wall (Figs. 16.2 and 16.3). Problem shooting: If the stomach does not easily reach the anterior abdominal wall, reduce the pneumoperitoneum pressure.
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