288 Section VII ■ Tube Replacement

frequently, a balloon retention tube (MIC-Key® or

AMT® button gastrostomy tube).

The purse-string is tied down to secure the gastrostomy tube in place.

7. The abdomen is reinsufflated and the laparoscope is

reinserted to confirm placement.

G. Laparoscopic Percutaneous

Endoscopic Gastrostomy

Laparoscopic gastrostomy may be difficult to place in neonates or children with thick abdominal walls. Some surgeons recommend the use of laparoscopic PEG. Other

indications for laparoscopic PEG include failed PEG

attempts, altered anatomy secondary to previous operations,

and when combined with another laparoscopic procedure

(11,13). It is basically a hybrid of the laparoscopic and percutaneous techniques to prevent hollow viscus and solid

organ injury and confirm accurate placement.

1. A laparoscope is inserted through a supra-umbilical

incision and the abdomen is moderately insufflated to 8

to 10 torr.

2. A standard PEG procedure as previously described is

completed under direct intra-abdominal visualization.

3. Additionally, in order to secure the stomach to the

abdominal wall, 2 to 4 T fasteners may be placed percutaneously through the gastric wall with laparoscopic

visualization.

H. Image-guided Percutaneous

Gastrostomy

A recent advance in minimally invasive gastrostomy placement utilizes fluoroscopy to guide percutaneous gastrostomy placement. Interventional radiologists typically perform this technique (14,15).

1. Insufflation of the stomach with an oro- or nasogastric

tube.

2. A needle is advanced into the distended stomach under

fluoroscopic visualization.

Contrast injection confirms intragastric positioning.

3. T fasteners (2 to 4) are advanced into the stomach to

secure it to the abdominal wall.

4. A second needle is then inserted in the center of the T

fasteners and again is confirmed by contrast injection.

5. A wire is advanced through the second needle and the

tract is dilated over the wire.

6. A balloon-type gastrostomy tube is inserted into the

stomach over the wire and positioning is confirmed

with contrast injection.

7. The T fasteners are tied externally over abdominal

bolsters.

I. Emergent Percutaneous Gastric

Decompression

The ability to decompress the stomach urgently is a lifesaving measure that may be required in neonates who have

severe respiratory compromise or a high probability of gastric rupture secondary to the presence of extreme gastric

distention.

1. Primary indication

a. Respiratory failure secondary to massive abdominal

distention that cannot be decompressed by either

an oro- or nasogastric tube. For example, premature

neonates with esophageal atresia and a tracheoesophageal fistula (prerepair) with massive gastric

distention from preferential ventilation of the compliant stomach rather than the stiff premature

lungs.

2. Procedure

a. Prepare the abdomen with Betadine or chlorhexidine and then drape the skin in the upper left abdomen.

b. If possible, utilize a light to transilluminate the

abdomen to locate and verify the position of the distended stomach away from liver.

c. Make a small skin weal with 1% lidocaine to provide

local anesthesia.

d. Using a 20- or 22-gauge catheter with needle stylet,

puncture the abdominal wall at the junction of the

left anterior rib cage and the lateral border of the

rectus abdominus muscle.

e. Advance the needle through the wall into the stomach.

f. Remove the needle and advance the catheter into

the stomach.

g. Attach a short IV extension tubing, three-way stopcock, and syringe.

(1) Aspirate only enough air to relieve tamponade

effect and improve ventilation.

(2) Avoid completely emptying stomach.

h. Secure the catheter and keep in place until surgical

evaluation is possible.

i. Secure with tape or suture if necessary.

J. Postoperative and Maintenance

Gastrostomy Care

Postoperative gastrostomy care begins immediately with

meticulous attention to wound care to prevent infection

and skin irritation. Initiation of feeds through the new

gastrostomy tube may begin within 12 to 24 hours postplacement. Certain complications, however, such as a

postoperative ileus, as seen in more complicated operations, may require further bowel rest prior to gastrostomy

feeding.