286 Section VII ■ Tube Replacement

D. Stamm Gastrostomy (Open)

Neonatal gastrostomy placement often necessitates general

anesthesia. Classically, the open, or Stamm, gastrostomy,

described by Dr. Martin Stamm in 1894, was frequently

used in premature infants and neonates (2). The Stamm

technique, however, is now being used with less frequency

secondary to its invasive approach. Current indications

include altered gastric anatomy, multiple previous abdominal surgeries, concurrent laparotomy for other procedures,

and unstable patients.

1. Sterile preparation of the skin, and delivery of IV antibiotics (first-generation cephalosporin) within the hour

prior to the skin incision.

2. Transverse abdominal or supraumbilical midline incision (Fig. 41.1).

3. Identify the stomach and elevate the greater curvature

of the stomach through the wound.

Choose a dependent portion of the anterior wall of

the stomach.

4. Place two concentric, seromuscular purse-string sutures

on the greater curvature of the stomach (Fig. 41.2).

a. The inner purse-string suture allows for hemostasis.

b. The outer purse-string suture inverts the gastric

mucosa while fixating the stomach to abdominal

wall.

c. Take care to avoid injury to the gastroepiploic vessels.

5. Make a stab incision through the stomach wall (gastrostomy) in the center of the purse-string absorbable

sutures.

a. With a stylet inside the catheter, gently direct the

catheter through the gastrostomy.

b. Verify position of the tube inside the stomach.

c. Inflate the balloon if present.

6. Tie sutures.

a. The inner suture secures the stomach around the

catheter while providing hemostasis.

b. The outer suture allows for mucosal inversion and a

watertight abdominal wall to stomach wall seal.

7. At a separate and previously identified exit site, make a

stab wound through the abdominal wall.

8. Insert a curved hemostat through the abdominal wall

exit site and into the intraperitoneal cavity.

9. Secure the stomach and abdominal wall to each other

with three to four absorbable sutures in a seromuscular

fashion.

10. With the hemostat, pull the gastrostomy tube through

the abdominal wall stab wound until the stomach is

snug against the abdominal wall.

11. Tie the previously placed inner and outer sutures while

placing gentle traction on the gastrostomy tube.

12. Secure the gastrostomy tube to the skin with a suture to

prevent inadvertent removal (Fig. 41.3).

Document the length of the gastrostomy tube outside the abdomen.

13. Close the abdominal incision in standard surgical fashion.

14. Anatomically, this will allow the gastrostomy tube to lie

in the center of a triangle formed by the left costal margin, umbilicus, and xiphoid (Fig. 41.1).

15. Tubes utilized in a Stamm gastrostomy include balloonand mushroom-tip catheters, and/or low-profile buttons

(e.g., Mic-Key buttons, Kimberly-Clark Worldwide,

Inc., Neenah, Wisconsin).

Fig. 41.1. Landmarks for gastrostomy. The primary horizontal

incision is left supraumbilical. The gastrostomy tube will pass

through the abdomen at a separate site in the center of a triangle

formed by the xiphoid, umbilicus, and left costal margin.

Fig. 41.2. Site for concentric sutures for Stamm procedure.

Entrance into stomach is on greater curvature midway between

esophagus and pylorus.