The open approach for gastrostomy is typically performed via a short supra-umbilical midline incision. To ensure minimal tension, the stomach is manually retracted toward the abdominal wall to visually assess its future apposition against the parietal peritoneum of the anterior abdominal wall. Depending on the patient’s body habitus, the greater omentum may need to be partially divided from the greater curvature of the stomach to allow for less tension when sutured to the abdominal wall. A stab incision is made on the left upper quadrant away from the epigastric vessels approximately three fingerbreadths below the left costal margin. A simple purse-string of 00 silk is placed around a future gastrotomy. A gastrostomy tube is then delivered via the stab abdominal incision through a sub-centimeter gastrotomy. Four to six stay 000 silk sutures are placed in a diamond shape appearance around the tube, and these are then sequentially secured to the parietal peritoneum circumferentially around gastrostomy. For better visualization of these suture placements, the assistant surgeon should carefully retract the left abdominal wall laterally using Kocher instruments on the fascia. The gastrostomy tube is then flushed and connected to gravity to ensure drainage of gastric contents. The 000 nylon sutures are then placed to secure the tube to the skin to minimize the risk of accidental removal.

Postoperative care of the gastrostomy tube after surgery includes regular flushing with water by the nursing team to ensure its patency. Postoperative local wound inspection and care are both important to detect and treat early surgical site infection. The balloon is usually kept inflated at all times. However, caution should be exercised when the balloon is fully inflated as it may migrate to occlude the distal stomach leading to
gastric outlet obstruction or may erode through the abdominal wall if constantly lying against the abdominal wall leading to pressure necrosis. In the event of accidental or premature removal of gastrostomy tubes, the operating surgeon should decide whether this gastrostomy tube needs to be surgically reinserted in the operating room (in the early postoperative phase) or should be reinserted after radiologic contrast study to ensure safe intra-gastric placement.

The laparoscopic technique is utilized in the patients with previous laparoscopic or open operations, depending on the comfort level of the advanced, laparoscopic surgeon with the anticipated degree of laparoscopic adhesiolysis. After routine preparation and induction of general anesthesia, a left upper quadrant Veress needle is used to access the peritoneal cavity and carbon dioxide insufflation to 15 mm Hg is utilized. For the patients with prior open surgery, direct high-definition optical viewing access with a 10 mm 0 degree laparoscope inside the port is utilized in a location predicted to be free of adhesion. Two additional working ports (5 mm and 12 mm) are placed in the right upper quadrant with triangulation directed at the left upper quadrant. Additional 5 mm ports are added if necessary. Lysis of adhesions is performed so that direct visualization of the body of the stomach is achieved.

A convenient site is chosen for the gastrostomy. If gastrostomy is performed after gastric bypass, the location may be affected by an antegastric Roux limb, which may be located directly anterior to the gastric remnant. If ERCP is indicated, a site closer to the pylorus (medial to the Roux limb) is chosen so that the scope may be directly aimed at the pylorus. Using a Stamm technique, four long nonabsorbable 00 sutures are circumferentially placed using a laparoscopic suturing device in a circumferential configuration around the planned gastrotomy site. The two ends of each suture are pulled transabdominally through stab incisions in the left upper quadrant using a suture-passing device and each pair is tagged individually. A 20-Fr balloon-retaining gastrostomy tube is passed through the stab incision in the skin, a gastrotomy is made using ultrasonic laparoscopic endoshears in the middle of the sutures, and the tube is manipulated into the remnant. The gastrostomy balloon is inflated with 10 cc water. An inner concentric pursestring of 00 suture is then placed around the gastrotomy and tied to seal the opening. Under direct visualization, the pneumoperitoneum is slowly released and the four outer sutures are pulled up to parachute the stomach and the gastrostomy tube toward the abdominal wall without tension. Each suture is tied, the tube is secured to the skin using 000 nylon, and it can then be used for calorie and micronutrient alimentation or can be placed to gravity or low continuous wall suction for decompression. The tube is cared for in the same manner as described earlier.

When ERCP is planned after gastric bypass, the four outer sutures are placed as described earlier, and a generous gastrotomy is made. A 15-mm port is then passed through the left upper quadrant future gastrostomy site directly into the gastric remnant, and it is directed toward the pylorus. The excluded stomach is parachuted toward the abdominal wall while desufflating the abdomen for the duration of the endoscopic procedure. At the end of ERCP, pneumoperitoneum is reinstituted and the gastrotomy is closed using an inner layer of 000 absorbable suture in Connell fashion followed by an outer layer of 00 non-absorbable suture to secure the closure. A gastrostomy tube may also be placed as described earlier in the event that follow-up ERCP or stent retrieval is necessary.

Surgeons may be asked to place a surgical gastrostomy tube in the patients who were not eligible for PEG after consultation with interventional radiology or gastroenterology or in the patients in whom PEG was attempted and aborted. Inadequate transillumination and one:one indentation or overlying bowel seen on CT scan may be the reasons for surgical consultation. The exact reason for failure should be understood by the surgeon and an alternative pathway or technique may be considered after careful cross-disciplinary discussion.

The surgeon must utilize several opportunities that can be achieved in the standard operating room, which may not be available to the colleagues utilizing endoscopy or radiologic procedure suites. Steep reverse Trendelenburg positioning displaces the colon inferiorly and direct intragastric insufflation lowers the body of stomach below the costal margin. Many times, PEG placement can be achieved by transillumination and one:one indentation after these manipulations alone. Video fluoroscopy using a C-arm can also facilitate localization of the colon and provide a greater margin of safety. In some cases, the edge of the liver blocks transillumination, but safe PEG placement can still be achieved when the colon is distant. Use of ultrasonography may also be of assistance in identifying the liver.

In the patients with altered gastrointestinal anatomy, PEG may still be achieved using deep small bowel enteroscopy to access an excluded gastric remnant, and direct stick, image-guided PEG is performed using two general approaches. In the first approach, insufflation of the gastric remnant is achieved by using endoscopic ultrasound to locate the remnant adjacent to the pouch and by placing a needle into the remnant. In this manner, the remnant is viewed with fluoroscopy and is directly accessed through the abdominal wall with a 25-gauge spinal needle. Air aspiration and then radioopaque dye injection confirms positioning, and an introducer needle and wire are placed using the same pathway. T-fasteners are used to fix the remnant to the abdominal wall in circumferential fashion. The pathway is serially dilated under fluoroscopic guidance and a balloon-retained gastrostomy tube is placed into the remnant. Radiopaque dye injection is used to document positioning.

In the second approach, tools are being developed to overcome the inherent limits of conventional push enteroscopy and allow deep small bowel enteroscopy. One of these devices (Spirus) utilizes the pulling force of a spiral overtube to pleat small bowel and advance the enteroscope. In this manner, the Roux and biliopancreatic limbs of a Roux-en-Y gastric bypass may be traversed, and the gastric remnant is accessed retrograde from the duodenum into the gastric remnant. Under direct optical visualization and with air insufflation, the PEG is then achieved using either an inside out technique or with a direct stick technique as described earlier.