Laparoscopic Gastrostomy in Infants During an Open Abdominal Procedure: A Novel Approach

Introduction

Gastrostomy tube (GT) placement is one of the most common pediatric surgical procedures and is utilized to provide enteral nutrition to patients who are unable to maintain adequate oral nutrition. ¹ Patients requiring GTs often have neurological, cardiac, pulmonary, or renal disorders, resulting in failure to thrive, malabsorption, problems with aspiration, or oral aversion.^2–4 Regardless of the etiology of the child's feeding difficulties, GT placement is considered when nutritional requirements cannot be met orally. ⁵ Since its introduction as a surgical procedure in 1894, there has been evolution in its technique and a reduction in the frequency of complications associated with the procedure. ⁶

In addition to the traditional open technique, GT placement can also be performed using minimally invasive approaches in the form of endoscopy (percutaneous endoscopic gastrostomy—PEG) or laparoscopy. Although some studies of smaller cohorts suggest there is no difference in complication rates among the three techniques, a large meta-analysis from 2017 concluded that percutaneous endoscopic placement was associated with more injuries to adjacent bowel, early tube dislodgements, and complications requiring reintervention.^4,7,8

The authors cautiously recommend laparoscopic gastrostomy as the preferred technique in children. ⁴ Laparoscopy, as opposed to the endoscopic technique, allows for direct visualization during gastrostomy insertion and allows for more precise placement of the feeding tube based on the patient's unique anatomy. These benefits have resulted in an increased preference of placing GTs laparoscopically as a safer and equally minimally invasive alternative. ⁹

Often, children undergoing operative intervention for various abdominal procedures (e.g., ostomy reversal, bowel resection or congenital diaphragmatic hernia repair) will also require GT placement due to poor oral skills and/or intake. At our institution, we began to place GT laparoscopically at the conclusion of an open abdominal operation in select patients, either through the partially closed laparotomy incision or through a separate umbilical incision once the open abdominal incision was closed.

The gastrocutaneous tract is quite sensitive in the early postoperative period, therefore, to prevent disruption and limit the conduct of the open abdominal operation, we perform gastrostomy at the end of the procedure. This laparoscopic approach affords excellent visualization in infants when the upper abdomen would not be otherwise easily accessible with an open operative approach. This technique has not yet been described in the literature and represents an innovative minimally invasive approach to a common procedure that can be performed concomitantly with open abdominal operations, especially in those with limited abdominal domain. We aim to demonstrate feasibility of this approach.

Methods

After institutional review board approval (No. 17080493), a single-institution retrospective review was conducted of children who underwent laparoscopic gastrostomy at the time of an open abdominal operation between January 2010 and June 2020. Operations were performed by 1 of 8 pediatric surgery faculty. Demographic data, baseline characteristics, operative details, and follow-up information were recorded. The primary outcomes were intraoperative complications, perioperative complications, and 30-day morbidity.

Operative technique

The left upper quadrant is marked at the beginning of the procedure to identify the appropriate location of the GT while avoiding encroachment on the costal margin (approximately one finger breadth). After completion of the primary abdominal procedure, the laparoscope port is placed either through a new umbilical incision or through the partially closed laparotomy incision if the umbilicus had been incorporated into the open incision (Fig. 1). At the premarked site, a 3 mm incision is made in the left upper quadrant and an atraumatic grasper is placed through the incision without a port. The stomach is grasped at the midbody near the greater curvature and pulled up to the abdominal wall.

OPEN IN VIEWER

FIG. 1.

Laparoscopic access.

Under laparoscopic vision, two large-gauge absorbable sutures are placed through the abdominal wall, incorporating a seromuscular bite of stomach (one cephalad and one caudad to the anticipated gastrotomy site), then passed back out of the abdominal wall, typically in one throw with an external needle driver. These sutures support the stomach while a needle is placed through a stab incision and into the gastric lumen. A guidewire is passed into the gastric lumen and the gastrostomy tract is sequentially dilated over the wire followed by passage of a gastrostomy button of an appropriate size and length. Appropriate placement is confirmed by insufflation and desufflation of the stomach through the GT and circumferential inspection with the laparoscope. ¹⁰

Results

Twelve patients were identified and included in our review. Open procedures included four ileostomy closures, two jejunostomy closures, two ileocolic anastomoses, one ileorectal anastomosis, one enterostomy closure, one omphalocele closure, and one repair of a recurrent congenital diaphragmatic hernia. The median gestational age was 35 weeks [IQR 26, 38]; 4 (33.3%) patients were considered extremely premature with a gestational age of <28 weeks.

Sixty-seven percent (n = 8) patients were male; the median age at the time of surgery was 10 weeks [IQR 6, 14], and the median weight was 4.1 kg [IQR 3.4, 4.8] at the time of the procedure. The majority (n = 10, 83.3%) of patients had one prior abdominal operation, whereas 1 (8.3%) patient had two prior abdominal operations, and 1 patient (8.3%) had no prior abdominal surgeries. Descriptive data concerning the open procedures are given in Table 1.

The median total operative time was 106 minutes [IQR 80, 124.5]. Utilization of the partially closed laparotomy incision was performed in 10 (83.3%) cases, whereas 2 (16.7%) had a separate umbilical incision made after open abdominal incision closure. There were no intraoperative complications.

One patient required reoperation within 28 days for persistent GT malfunction. Trivial GT leakage occurred in 3 (25%) patients, whereas 5 (41.7%) experienced a superficial surgical site infection (SSI). SSIs were all located at the G-tube site. Postoperative follow-up was noted for a median of 1115 days [IQR 290, 1707]. A total of 7 patients (58.3%) already had their GT removed at a median time of 252 days [IQR 150, 1377] after insertion. Persistent gastrocutaneous fistula was identified in 5 of those patients after GT removal, all of whom required operative closure.

Discussion

In this retrospective review, we describe our experience with placement of GT laparoscopically during concomitant open operations. Our review demonstrates initial safety and feasibility with a technique, which has not been previously described. Infants who need abdominal operations often require GT for enteral nutrition. However, utilizing an open technique can be difficult in infants due to limited working space in the abdomen, limited visibility, and higher reported complication rates. ¹¹ We developed a technique to utilize laparoscopy during an open operation in infants requiring gastrostomy to mitigate these concerns. In the 12 patients who underwent laparoscopic gastrostomy at the time of an open abdominal operation, there were no intraoperative and only minimal postoperative complications.

One of the most important indications for GT placement is improvement in quality of life through effective enteral nutritional optimization. This must be balanced against the risk of surgery. The benefits of laparoscopic GT as opposed to PEG placement include direct visualization of anatomy, and the ability to suture the gastric body to the anterior abdominal wall. ¹⁰ Close apposition of the stomach to the anterior abdominal wall is vital to the prevention of intraperitoneal contamination while a permanent tract forms. Both the open and PEG techniques are known alternatives but have not been shown to be superior to laparoscopy.

Multiple analyses have demonstrated worse outcomes with an open approach for GT placement, compared with laparoscopy. These include SSIs, wound dehiscence, and bleeding or transfusion after surgery.^11–15 Therefore, in a population with a higher risk for both operative and postoperative complications, we were able to demonstrate the feasibility of laparoscopic GT placement during concomitant open operations, providing an alternative for these complex patients.

Likewise, previous research has shown a benefit to laparoscopic GT placement compared with PEG tube placement, a technique commonly utilized in the adult population. A 2017 meta-analysis identified a >5 times higher risk of adjacent bowel injury in patients undergoing PEG, and a >7 times higher risk of dislodgement when compared with those having a GT placed laparoscopically. ⁴ Open gastrostomy continues to be performed in up to 20% of patients, with the most common indication being the concurrent placement of the feeding tube at the time of another open procedure.^11,12

Piening et al. performed a National Surgical Quality Improvement Program database analysis comparing open and laparoscopic GT placement complications that demonstrated that complications and readmissions were much more frequent in patients who underwent open gastrostomy, compared with the laparoscopic alternative. ¹¹

Safety of the technique was demonstrated, as there were no intraoperative complications during the laparoscopic placement of GT, providing an alternative for GT placement in this complex patient population. Postoperative complications included SSI in 5 (41.7%) patients, leaking around GT in 3 (25%) patients, and operative replacement in 1 (8.3%) patient within 30 days due to tube dysfunction.

This study has several limitations. The retrospective nature limits the data available through the electronic medical record. As this study was not randomized, the patients in which this procedure is performed were specifically selected based on patient characteristic and surgeon preferences. In addition, the small sample size of 12 patients does not allow for statistical conclusions. Future studies are needed to compare outcomes of open GT at the time of surgery with those of our approach, as well as comparing the risks and benefits of performing the GT at a separate operation. However, the purpose of this analysis was to demonstrate feasibility of this approach.

Conclusion

We describe the technical feasibility and safety of performing a laparoscopic GT at the time of an open operation, which can provide an alternative to enteral access placement in complex patient populations.