Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

CHAPTER 1

My name's Katherine Albutt.I'm one of the trauma surgeons at Mass General.Today we're goingto be seeing a laparoscopic feeding tube placement.That is going to be a laparoscopic-assisted PEG placement.This is an unfortunate patient who's been in a comaafter a cardiac arrest,who's also had a prior sleeve gastrectomy.And as a result of the sleeve gastrectomy,people have been unable to place a feeding tubevia our other traditional meansbecause they've been unable to get a windowto safely access the stomach.So that's why we're here today.The key steps of this procedureare going to be entering the abdomen safelyand establishing pneumoperitoneum,looking around and making sure we can visualize the stomach,and then under direct laparoscopic visualization,picking a point on the abdominal wallwhere we can enter with the needleand ensure that direct access into the stomachwithout traversing any other structures.Once I'm into the stomach,the residents who are gonna be at the top of the bedwill grasp the wire I insert into the stomachand pull it out endoscopically.From there, they're gonna load the gastrostomy tubeonto the wire,and I will then be able to pull the gastrostomy tubeall the way through the mouth, down into the stomach,and out of the abdominal wall.All while watching it under the laparoscopic camera visionto see that the stomach is getting nicely opposedto the abdominal wall.

CHAPTER 2

Thank you.So I'm gonna use the Veress needleto get into the abdomen.I'm cheating a little bit and coming further to the sidebecause of his prior sleeve gastrectomy.So if I were normally putting in a Veress,I would put it close here where this incision is.But I'm cheating out herebecause I know he's had an operation and his stomach is here.Let me know if you're happy with that tube once you...Is it to suction?Yeah, it is to suction.Okay, perfect.I want to make sure it's in a good spot.How far in is it?It's only 40. Yeah.Does it go further?Well, it wasn't, but maybe now that he's...No, he's like fighting it.Yeah, he's still coughing. Yeah, let's give him some time.Yeah, it's going to take a few minutes.Yeah, he's...In the meantime, can we elevate the table? Yeah.That's good there. Thank you.Still at 40?Yeah, I was just pulling this down here.That's it.Can I have the knife?Opening pressure is four.Can we have some local up?Thank you.Just gonna give some local,and I'm gonna put the Visiport in down here,so I'm far away from the stomach.Can I have a 15 blade, please?Blade.Thank you.We are insufflating. Are we doing okay pressure-wise?Yeah, we're doing fine.Can we turn up the flow, please?Our flow is very low.There we go.All right, so that was our accessinto the abdomen.

CHAPTER 3

The next thing we're gonna do is lookright up at where we put this Veress needle inand make sure that I didn't hurt anything by doing that.And you see how far lateral I came,but there's adhesions right here,so that's why I cheated that far lateral.So here's his sleeve stomach.All right Lucky, you can get in and you can insufflate.

CHAPTER 4

All right, so we're gonna start the endoscopy portion now.If I can blow up the stomach successfully,then we're gonna put in a PEG,and I'm just gonna watch it happenunder laparoscopic guidance.Guys, can we give him another dose of paralytic?I think part of the reason we're having problems is-Yeah, I just did.Thank you.Dylan, you can turn the flow back down to like 10.Can you guys help her with a little jaw thrust, please?All right, so you just saw your Dobhoff, right?So, follow that.Leads you to the way.So blow air continuously and advance down that hole.Keep going. Keep that in the middle of the screen.Down. Look down.It's to the right.So go back, find the tube.Once you find the tube, you gotta chase it downand keep it in the middle of your screen.So, you should only need to use two knobs,and the rest is in your wrist.You're pushing against the mucosa here, so back up.Clean your screen.Clean your screen with some water.If you just hold the button.It should clean.Okay.All right.Now follow it down.Blow as you go. You need insufflation.Look up.There. Go.What's the problem?Push through that.Look up.Push down.Now I can't see anything.All right. Push, push, push.Keep blowing.Push down.Keep it in the middle of your screen. Yep.Push down. Okay, here we go.Keep going.Keep the lumen in the middle of the screen.Back up. You're against the sidewall.So, find the lumen. It's right there.Go through it.Go ahead.Push in, push in, push in.Push in. Look down.Push in, push in.Look down.Look down.Back up. Find your lumen.Okay.Clean your screen.So, make it simple.Back up. Clean your screen.Back up.Hey.Can you just - can Tom come over and scope quickly.Sure, yeah, yeah. I can send him over.Thank you. Yeah.Okay, good.Keep pushing. All right.So you are in.Keep pushing.Hey.Push.Keep the lumen in the middle.Hey, can you help her with the scope?Push in some more.Gonna put in another port.Can I have the knife, please?Blade.

How are we doing blood-pressure-wise?Fine.Bowel grasper? Yep.Thanks.He's asleep.Yeah, there you are. Yeah. All right, I see you.Can you advance any further? Yeah.And if you blow up,is that the amount that you blow up?Yeah, I've been holding the gas now.The pylorus is…

CHAPTER 5

That's Kat messing with you, Tom.That's me.Can you pull back?Yeah.All right, just sit on it there for a second.Yep.Can we drop the intra-abdominal pressure,Dylan, please?Okay.You're at nine.All right.Thomas, can you insert your grasping device,so that the moment I enter the stomach you are thereto grab it?Yeah, can you look up a little bit moreabove that?I need to see the stomach too, so you can't -yeah, that angle I think it's the...Ribs are up here.That's gonna be the way to go.You're still sitting on the...Yeah, advance your camera in more, Lauren.The port too, please.

No. So I'm gonna need you to pass the catheter to me -the wire very quickly.Okay? Because...Perfect. Nice.

Can you hook me now?Yep.You gotta close a little bit, Lucky.Close a little bit, a little bit.That's it. Perfect.Okay, death grasp.Okay, you're as tight as you can be?

Get ready to come out as you guys go in. This is a death grip.All right, ready? Go ahead.Okay, just come off of it, Lucky. Yep, come off. I'm free.All right, we'll close it up.Pull it all the way out.

CHAPTER 6

So the reason we did it this waywas because IR had failed to place this G-tube twicebecause of the sleeve gastrectomyand because it was buried a little bit under the colon.So all I did was move it out from under the colon,thread this wire into the stomach,which they have now pulled up.Lauren, pull back into the port.And now they're gonna put the feeding tubein through the mouth.I'm gonna pull it up out of the stomachand up through the abdominal wall.Perfect. Good to go.All right.Scoot back in.Are you? Yeah.Perfect, just like that is great.You can advance the port all the way inand then stay right there.Perfect.All right. Ready to go?Yeah.The thing I want to do here is make sure I'm nottenting the stomach up too aggressively.All right, can I please have scissors that cut?And then grab the bumper and the other two pieces.

CHAPTER 7

I'll take the bumper.Thank you.And then we'll take the clamp and the end.Lauren, right where you are is perfect.Can you just zoop back into the...Yep.Oh, I'm losing insufflation now.It's sideways.I'm sorry, I can't get you a better angle.Yeah, that's fine.Sideways works.I decreased all of the intra-abdominal pressureso I could make surethat the stomach reaches the abdominal wall without tension,without me pulling this through.You can see the stomach opposing the abdominal wall there.

And then we're just gonna confirmthat it's still mobile within the stomach.Lauren, can you show me again quickly?There you go.Nice.Drive in up here.Woop-de-do.Looks like we're pretty well-opposed there.Yep.You wanna glue it?Sure, we can glue.We can do whatever you want.There we go.All right, I'm gonna desufflate.

CHAPTER 8

Lauren, you can come out with the camera into the port.Yep. Thank you.All right, stomach is up.Look.Beautiful.One quick second.All right, you can come out.The other way? Yep.All right, we are done.Okay, thank you.How much do we have up?We have 30 - so, in total.Thank you for your help, Lauren.You're welcome.I will need the Bovie for a second.You guys want some light back on?That would be fabulous.And then we're just gonna throw insome subcuticular stitches to close these ports,then we are done.Thank you.Oh, cut it off?You cut that part off,and then... This goes on here.That Bovie's about to fall. Thank you.You can also put a binder on him,it might secure us.He was in restraint.If he was in restraints, then yes, please.You can cut a hole for the...So this one stays to gravity for 24 hours.No meds until we see him tomorrow, and no feeds, okay?Thank you.No, no. We just put the PEG to gravity.Voila.All right, I will take the glue.You gave 17 of local total.Are you gonna give anymore?Nope. Okay.Thank you. Dylan, just 17 of local.17? Yep.Okay.

CHAPTER 9

In this particular case,the pertinent things were that,first of all, I accessed a little bit laterallyto make sure that I wasn't going to runinto any adhesions from the prior operation.So when I inserted my Veress needle, it was quite lateral.I was able to get good insufflation of the stomach,which the patient tolerated pretty well,but it was pretty clearthat the stomach was buried behind the colon,so we had to move the colon out of the wayin order to see the stomach.Even with the residents insufflating the stomachwith the endoscope,the stomach didn't really descend in the normal way.Again, that's because of his anatomywith the prior sleeve gastrectomy.What I did at that pointwas then lower the intra-abdominal pressurein order to assure that I could get the stomachup to the abdominal wall safelywith nothing in between the stomach and the abdominal wall.When I was sure I could do that,I then access the stomach and pass the wire,and then the rest of the procedureis as I had intended it to be.So going forward,this is a little bit of an atypical approachto a gastrostomy tube placementbecause of the patient's prior surgery.The important things to keep in mind for him are,because it's a little bit atypical,I'm gonna hold off on his tube feeds for nowuntil tomorrow morning.Normally, if this was just a routine PEG,I would start giving medications immediatelyand tube feeds in four hours.But because this was a lap-assisted one,I'm gonna hold off until tomorrow morning.So we'll examine him tomorrow morning.If his belly is soft and his tube is functioning well,we'll be able to give him meds and tube feeds,and he'll then be able to finally get out of the hospitaland get to his long-term rehab.