Obtain access through an infraumbilical incision. Identify the stomach. Place a second trocar through a right upper quadrant site (Fig. 50.1A) and insert an atraumatic grasper. Grasp the stomach and manipulate it until a suitable site high on the fundus is located. Confirm that it will pass easily to the underside of the anterior abdominal wall at the chosen location.

Make an about 1-cm skin incision at the proposed site. Through the skin incision, insert a 14-gauge needle. Under direct visualization, puncture the stomach with the needle at the chosen location. Use the grasper to stabilize the stomach, facilitating puncture. Confirm that the needle is in the stomach by injecting and aspirating air or saline. Pass a guidewire into the stomach. Using a Seldinger technique, follow the guidewire with a dilator and finally a sheath through which an 18-French gastrostomy tube (commonly called a Foley catheter) can be inserted into the stomach. Withdraw the sheath and inflate the balloon. Snug the gastric wall up against the anterior abdominal wall by pulling back on the tube gently. It may be necessary to release some pneumoperitoneum to bring the anterior abdominal wall into closer apposition to the stomach.

T-fasteners (shown, Fig. 50.1B) are a simple method to secure the stomach to the anterior abdominal wall. Place these by passing a needle through the anterior abdominal wall and stomach. Insert the closed T-fastener through the needle and snug it up. Alternatively, use a couple of simple sutures of 3-0 silk to tack the stomach to the anterior abdominal wall. Either method helps minimize the chance of leakage and increases the safety of the procedure by giving additional assurance that the stomach will be maintained in close apposition to the anterior abdominal wall during the healing phase.