Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

Case Overview

For long-term enteral nutrition, percutaneous endoscopic gastrostomy (PEG) is considered the standard of care; however, it often leads to a number of complications: tube migration, blockage, inadvertent tube slipping and removal, and less often, perforation.¹ PEG involves insertion of a feeding tube through the skin and into the stomach, with the assistance of endoscopic intraluminal visualization of the stomach. PEG is a blind procedure, making it difficult to detect organs interposed between the stomach and the abdominal wall (e.g., colon, small intestine, greater omentum). To avoid these complications,¹ laparoscopic-assisted PEG (LAPEG) was introduced.

LAPEG tube placement stands out as a minimally invasive surgical intervention that combines the techniques of laparoscopy and endoscopy to establish enteral access for nutritional support. The laparoscopic approach provides visualization for the feeding tube insertion and for approximation of the gastric and abdominal walls. This method proves particularly beneficial for individuals who require long-term enteral feeding while having obstacles with conventional approaches to stomach access due to diverse medical conditions.² The merits of this approach extend to reduction in postoperative discomfort, expedited recovery time, and a diminished risk of infection compared to conventional open surgical techniques.³ Multiple studies have demonstrated a success rate of 100% and no reported postoperative complications with this surgical technique.⁴

LAPEG presents certain disadvantages when compared with PEG. LAPEG requires general anesthesia, the use of a tracheal tube, and the collaboration of an extensive team of professionals. Furthermore, it is associated with extended operative durations and high costs in comparison to PEG. These considerations advocate for the wise application of LAPEG, reserving its use for cases where it is distinctly indicated.

On the other hand, PEG, when executed by a pair of experienced professionals demonstrating exceptional technical precision and thoroughness, is a procedure with a low complication rate.

A salient advantage of LAPEG is the ability to puncture the stomach under direct visualization, thereby avoiding the potential complication of blindly puncturing an adjacent organ, thus causing severe consequences. This discussion underscores the importance of careful selection and application of these procedures in clinical practice.⁵

Altered gastrointestinal anatomy following bariatric procedures can pose significant challenges in establishing enteral access for nutritional support. Here, we present a compelling clinical case detailing our approach to management of such a scenario. The patient, having previously undergone a sleeve gastrectomy, presented in a coma following a cardiac arrest. Confronted with the inability to safely access the stomach and two unsuccessful attempts at nasogastric tube (NG-tube) placement, the medical team was facing a complex situation requiring a nuanced solution.

This video provides a step-by-step visual guide for LAPEG tube placement. The procedure begins with marking of the left upper quadrant for peritoneal insufflation using a Veress needle. A small incision is made in the infraumbilical region, and the first port is placed to allow for the introduction of laparoscopic instruments. This step provides the surgeon with a clear visualization of the abdominal organs and aims to identify the optimal site for PEG tube placement. This exploration ensures that the chosen location is safe and free from major blood vessels or other structures that could complicate the procedure. Simultaneously, an endoscope is introduced through the patient's mouth and advanced into their stomach. Gastric insufflation is performed to distend the stomach, creating a clear workspace for tube placement. A second port is positioned in the right upper quadrant of the abdomen to help move structures away from the stomach. Under direct laparoscopic visualization, the operator identifies a suitable point of entry on the abdominal wall, carefully inserting a needle into the stomach, ensuring minimal disturbance to surrounding structures. Using the inserted needle, a wire is then threaded through the abdominal and gastric walls. Once inside the stomach, the wire is grasped and pulled out endoscopically and carefully guided out through the patient’s mouth, providing a path for the PEG tube placement. The PEG tube is secured to the wire and passed over through the mouth, down the esophagus, and into the stomach. Under laparoscopic guidance, the tube is then advanced through the stomach and the abdominal wall to the outside, establishing the percutaneous component of the procedure. The reduction of intra-abdominal pressure ensures a tension-free opposition of the stomach and the abdominal wall, sandwiched between the internal PEG bumper and its external retention disk, which help securely fix the tube in place. This step is crucial to prevent dislodgement and minimize the risk of complications. Once the PEG tube is securely fastened, the laparoscopic instruments are withdrawn, and the small incisions are closed with subcuticular sutures and topical skin adhesive.

It is advocated to secure the stomach to the anterior abdominal wall as well as securing the external retention disk to the skin with interrupted sutures to prevent the gastrostomy tube from migrating. However, based on the patient’s comatose state and apparent immobility, as well as the medical history of type 2 diabetes mellitus and hypoalbuminemia impairing wound healing, a decision was made not to use sutures in order to avoid excessive traumatization of tissues and exacerbating the risk of infection.

Postoperative care includes monitoring for any signs of complications, providing appropriate tube care instructions, and ensuring that the patient receives the necessary nutritional support through the newly placed PEG tube.

When managing such complex cases, the integration of advanced techniques such as LAPEG placement is critical, providing a customized, minimally invasive approach for intestinal access. This method shortens hospital length of stay and has a positive impact on the overall quality of life.⁶ Existing literature emphasizes the significance of prepyloric feeding, advocating for gastrostomy as a preferable option over prolonged nasogastric cannulation to enhance survival and avoid complications. PEG tube feeding is linked to a better 4-month complication-free survival rate and fewer tube-related complications compared to prolonged nasogastric feeding.⁷