LAPAROSCOPIC STAMM GASTROSTOMY IN ADULTS WITH ASCITES WITHOUT ENDOSCOPIC ASSISTANCE: A NEW AND NOVEL APPROACH
Vishal Chandel*, Umashankkar Kannan, Ranjan Gupta, Casey Joe, Venkata Kella
Surgery, BronxCare Health System, Icahn School of Medicine at Mount Sinai, Bronx, NY
OBJECTIVE:
This report describes a new technique for placement of laparoscopic gastrostomy tubes in patients with ascites. To our knowledge, this is the first description of this technique without any endoscopic assistance in such patients. The procedure was performed in 5 patients, all had mild-severe ascites. In this report, we aim to present a new laparoscopic gastrostomy tube (LGT) placement method developed in accordance with the classical Stamm method. We also aim to identify and characterize complications of the modified procedure.
MATERIALS & METHODS:
Charts were reviewed of all the patients undergoing LGT placement by modified procedure. The anterior wall of the stomach was identified and a purse string suture with 2-0 silk was placed, where the gastrostomy tube was intended to be placed. While purse-string sutures were being placed, the needle was passed through from a loop thread prepared by extracorporeal and the two threads are suspended outside. Two concentric circles of 2-0 silk purse-string sutures were placed on the anterior surface of the stomach close to greater curvature of stomach. The gastrostomy was made in the middle of the sutures. The stomach was punctured using hook diathermy, the gastrostomy tube was inserted, and both threads were knotted outside the abdomen. The two layers of purse string sutures were tied snug around the gastrostomy tube and tacked to the abdominal wall with 2-0 silk sutures. 18F Moss tube was inserted through another 5mm port in epigastrium into the stomach. No leak was noted on infusing the tube.
RESULTS:
Five patients underwent laparoscopic gastrostomy. There were no conversions to open gastrostomy. Three ports (5mmx3) were used in the patients. The mean follow-up was 13 months (range 2 - 24). No major complications were observed during surgery. One patient had tube dislodgement after 25 weeks. No wound infections, no cellulitis, and no stitch abscesses were seen. None of the patients had initial intraperitoneal placement, intraperitoneal location upon tube replacement, extraluminal migration, tube-related pressure necrosis, or procedure-related death.
CONCLUSIONS:
Our method is a feasible approach for gastrostomy tube placement without any endoscopic assistance by the purse-string suturing and the fixation of the stomach to the abdominal wall without extending the port incision in adult patients with ascites. It allows for the quick, accurate, and safe insertion of the feeding tube under direct visualization and avoids open techniques in patients where PEG tubes are not feasible. This modified technique also eliminates pressure necrosis from external stayin-sutures, provides improved adherence of stomach to abdominal wall, thereby preventing extraluminal migration and intraperitoneal tube replacement including avoiding additional visits for suture removal.
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