What is a laparoscopic gastrostomy insertion?
A laparoscopic gastrostomy insertion is the placement of a gastrostomy button into the stomach using a telescopic camera and a thin instrument under general anaesthesia.
What is a gastrostomy and why does my child need one?
A gastrostomy is an opening through the abdominal wall into the stomach. A feeding device is inserted through this opening, which allows your child to be fed directly into his or her stomach, bypassing the mouth and throat.
People who have difficulties feeding can benefit from a gastrostomy. There are many reasons why someone might have difficulties feeding, including neurological (nervous system) disorders and gastrointestinal (digestive system) disorders. Some people also have difficulty swallowing, which increases the chance that they will accidentally breathe in food (aspirate). Your doctor will explain to you the specific reasons why your child needs a gastrostomy.
What are the advantages of having a gastrostomy?
Gastrostomies are often useful for children who need to be fed slowly, or have had problems with feeding by nasogastric tube in the past. Overnight feeds are regarded as safer using a gastrostomy than a naso-gastric tube. Some families find a gastrostomy more acceptable than a naso-gastric tube as it can be hidden under clothing, is less likely to be pulled out accidentally and does not irritate the skin of the face. A gastrostomy can be a permanent or temporary measure, as it can be removed when your child no longer needs it.
What different types of gastrostomy are there?
Gastrostomies differ mainly in the way that they are inserted. At Great Ormond Street Hospital (GOSH), they can be inserted using one of four different methods:
Laparoscopic gastrostomy insertion
Percutaneous endoscopic gastrostomy (PEG)
Radiologically inserted gastrostomy (RIG)
Open surgical gastrostomy
At GOSH, children almost always have a general anaesthetic for gastrostomy insertion, whichever method is used.
The method used to insert a gastrostomy depends on many factors, including your child’s weight, medical condition, and previous or planned abdominal surgery. Your child’s doctor will explain why a particular method has been chosen as best for your child. This page only explains about laparoscopic gastrostomy insertion.
The initial tube placed with this technique is a soft rubber tube which is later changed to a low profile device (button) usually after six weeks. This later change does not require a general anaesthetic.
What is a laparoscopic gastrostomy?
A laparoscopic gastrostomy insertion is the placement of a gastrostomy button into the stomach using a telescopic camera and a thin instrument under general anaesthesia. It is performed by a surgeon in the operating theatre.
What happens before the gastrostomy is inserted?
Your child will usually come for a pre-admission assessment before the gastrostomy insertion. The assessment makes sure that your child is well enough for the procedure and is also an opportunity for you to ask questions. He or she might need to have some blood tests and/or some other tests before the gastrostomy is inserted, but we will explain what will happen before the assessment.
As your child will be having a general anaesthetic for the gastrostomy insertion, it is very important that his or her stomach is as empty as possible on the day of the procedure, as this reduces the risk of vomiting during and after the anaesthetic. If someone vomits during an anaesthetic, there is a chance that the stomach contents could get into the lungs, damaging them. Your child’s nurse will explain exactly what time your child can last eat or drink before the procedure, but as a general rule, the following applies.
Food and milk
Breast-fed babies – give them their last feed four hours before the procedure is scheduled.
Bottle-fed babies and children – give them their last milk feed, food or milk drink six hours before the procedure is scheduled.
Please follow these instructions carefully, otherwise your child’s procedure may be delayed or even cancelled.
The doctors will explain the procedure in more detail, discuss any worries you may have and ask you to give permission for the procedure by signing a consent form. Another doctor will visit you to explain about the anaesthetic.
What does the procedure involve?
Your child will be taken to the operating theatre and given the anaesthetic, either as an injection or by breathing gas in through a face mask.
Once your child is deeply asleep, his or her abdomen will be cleaned with antiseptic solution. A small incision (approximately 15mm) will be made near your child’s tummy button so that a telescopic camera can be passed inside to see the stomach and inside of the abdomen. Another incision is made (approximately 15mm) at the point where the gastrostomy is to be placed and a thin instrument is inserted to pick up the stomach wall.
The stomach is then stitched to the gastrostomy site and an opening made, into which the tube is placed and secured with another stitch. The incision at the tummy button is then closed using dissolvable stitches beneath the skin.
Are there any risks?
All procedures that break the skin carry a small risk of infection and bleeding. An antibiotic injection is usually given during the procedure to reduce the risk of infection. Every anaesthetic also carries a risk, but this is very small.
After effects of an anaesthetic include headache, a sore throat or feeling dizzy or sick, but these are not usually severe and do not last long. The anaesthetist will explain any specific anaesthetic risks for your child when he or she meets you before the procedure.
This particular method of gastrostomy insertion carries some specific risks. When the incision is made for the camera, there is a very small risk of the bowel being damaged. This would be repaired if it occurred during the same anaesthetic. One benefit of the laparoscopic technique is that it removes the risk of large bowel damage as the gastrostomy button is placed.
All gastrostomy sites may leak onto the skin or become inflamed where the device passes through the skin. These complications can usually be managed on the ward and at outpatient visits.
What happens after the procedure?
Your child will be taken back to the ward to recover from the anaesthetic and the procedure. He or she may remain a bit sleepy from the anaesthetic for a few hours afterwards but this is normal.
Your child will not be able to have any fluids through the gastrostomy tube for several hours after it has been inserted. The stomach needs this time to settle down and for the tissue to grip tightly around the tube so that stomach contents cannot leak into the abdomen. If stomach contents leak into the abdomen, this can lead to peritonitis, a potentially life threatening infection.
Before the gastrostomy is used and while the feeds are being introduced, your child will have an intravenous infusion (drip) of fluids to give them water and sugar. Once the gastrostomy has had time to rest, your child will start to have liquid feeds through it. This is done very gradually over a period of hours, increasing the amount of feed given each time. The team on the ward and at home will explain this to you.
Your child will be prescribed a special liquid feed, which contains all or most of the nutrients he or she needs. Please talk to your dietitian if you would like to know more about it. Some children can also continue to eat regular food by mouth, using the gastrostomy to ‘top up’ their nutrient levels, but this depends on the reasons why the gastrostomy is required.
Once your child has fully recovered from the anaesthetic and is starting to tolerate feeds well, you will be able to go home, unless any other procedures are planned. Usually, children stay in hospital for one or two nights, depending on how well they get used to feeding through the tube.
Your child’s feeds, equipment and other supplies should have been organised by your local team before coming to GOSH, so you should be able to start tube feeding your child straightaway once you return home. They will also have taught you how to prepare and give your child feeds, look after the gastrostomy site and spot any problems that occur. If you have any questions or problems, please contact your local team in the first instance.
Once the gastrostomy tract has settled down, usually after six weeks, we will make arrangements to change the rubber tube to a low-profile button device. It is held in place inside the stomach wall using an inflatable balloon and connector sets are used to give feeds. The initial change to a button does not require a general anaesthetic and similarly once the button is in place, it can be changed or replaced easily without the need for an anaesthetic.