Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
Introduction:  
 
 
Gastrostomy is used for patients with 
functional or obstructing lesions of the upper 
aerodigestive tract or esophagus. Indications  include 
obstructing tumors, severe infections, and inability to 
feed due to neurologic lesions or other severe illness. 
Administering feeds directly to the stomach makes 
use of its natural reservoir function, allowing feeds 
to be administered in bolus fashion several times per 
day.  
 
Gastrostomy is contraindicated in patients 
with obstruction of the pylorus or duodenum, or 
functional 
problems 
downstream 
such 
as 
anastomotic leakage in the small intestine. Such 
patients are better served by a jejunostomy. However 
jejunostomy is much more difficult to manage, 
requiring continuous rather than bolus infusion, and 
being more vulnerable to blockage of the smaller-
caliber tube.  
 
Percutaneous endoscopic gastrostomy (PEG) 
using a flexible fiberoptic gastroscope avoids 
laparotomy for tube placement, but requires 
specialized equipment as well as a non-obstructed 
upper gastrointestinal tract to allow passage of the 
scope. This procedure is discussed in a separate 
chapter.  
 
Both open and percutaneous gastrostomy 
make a hole in the stomach. After 5-7 days (but more 
reliably after 2 weeks) a tract is formed between the 
skin and the stomach. After that time, the tube can be 
changed if needed, or simply replaced if it falls out. 
If the tube becomes dislodged before 5-7 days post 
surgery, a repeat laparotomy may be required. In case 
of dislodgement of a recently placed tube, after the 
tube is returned to place, a contrast study should be 
used to confirm its position in the stomach. If the 
tube passes easily into the stomach when replaced 
and the operation was more than 2 weeks previous, a 
contrast study is not necessary.   
 
A variety of tubes can be used in resource-
limited settings, including Foley catheters, Malecot 
catheters, and dedicated gastrostomy tubes. Foley 
catheters are very common and are often used for 
gastrostomy, however the balloon must not be 
allowed to migrate across the pylorus or it will cause 
bowel obstruction. The problem with using a foley 
catheter for a gastrostomy is that it will forever be 
prone to either falling out if the balloon is not 
inflated, or migrating to the gastric outlet and causing 
obstruction if the balloon is inflated. The solution to 
both problems is to make sure it is well secured to 
the abdominal skin.  
 
Commercially available gastrostomy tubes have a balloon at 
the tip (Black Arrow) and a flange (Red Arrow) that can be slid 
along the tube. After placement of the tube, the flange is slid 
distally so that the gastric and abdominal wall are squeezed 
gently together by the inflated balloon on the inside, and the 
flange on the outside.  
 
 
In general, the steps of open gastrostomy 
placement are:  
● Mini-laparotomy 
● Selection of the tube placement site 
● Mobilization of the stomach into the surgical 
field 
● Placement of two purse-string sutures 
● Passage of the gastrostomy tube through the 
abdominal wall 
● Gastrotomy and passage of the tube into the 
stomach lumen 
● Closure of the purse-string sutures 
● Securing the anterior stomach to the abdominal 
wall 
● Fascial and skin closure.  
 
Steps: 
1. The clinical status of the patient as indication for 
gastrostomy tube placement is quite enough 
most of the time, but in case of esophageal 
obstructive tumor, an OGD should be done if 
not done previously to rule out the possibility of 
a PEG tube placement vs open.    
2. General anesthesia is preferred if there is no 
contraindication. If the generation condition of 
the patient puts the patient at high risk for 
general anesthesia, the procedure can be done 
under light sedation and local anesthesia.  
Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
3. The patient lies supine, prepared and draped 
from the inframammary line to the umbilicus. 
The surgeon stands on the patient’s right side. 
4. A 6cm long supra-umbilical midline incision is 
made at the epigastrium region, about 4cm 
below the xiphoid process.  
 
An incision about 6cm in length is made beginning about 4cm 
below the tip of the xiphoid process. The left lobe of the liver 
is usually immediately below this location and the stomach just 
to the patient’s left.  
 
5. The stomach is retrieved and an avascular area 
is identified on its anterior aspect at the greater 
curvature where the gastrostomy tube will be 
inserted. Make sure that this point will be easily 
mobilized without tension when anchoring the 
stomach to the abdominal wall.   
 
The stomach is usually freely mobile and the distal body can 
reach the anterior abdominal wall easily. Once the location 
for tube placement has been chosen, this part of the stomach 
is delivered through the abdominal incision. If intra-
abdominal adhesions prevent this mobilization or delivery, the 
incision can be extended for adhesiolysis.  
 
6. Two purse string sutures are done. The outer one 
remains with the needle which will be used to 
anchor the stomach to the abdominal wall. This 
suture starts and ends on the patient’s left. When 
the stomach is anchored to the anterior 
abdominal wall, the left-most anchoring stitch is 
the most difficult to place. Leaving the needle 
on after the purse string is tied allows this suture 
to be directly placed into the abdominal wall.  
Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
The inner purse string is placed first, the location it starts and 
ends does not matter.  
 
 
The outer purse string is then placed, starting and ending on 
the patient’s left. The needle is not cut off, so that this suture 
can be used to anchor the stomach to the abdominal wall after 
the tube has been placed.  
 
7. A small incision is made to the left of the 
laparotomy site, in the area where the stomach 
was found to reach without tension. A Kelley 
forceps is passed from the abdominal cavity, 
through the abdominal wall and then through the 
incision. The gastrostomy tube must be grasped 
on the very end to avoid tear of the balloon. The 
balloon of the tube must be tested before 
insertion to confirm its patency. 
 
Abdominal wall stab incision is made in the area where the 
tube will pass. A Kelley or similar forceps is then passed from 
inside the abdominal wall and used to grasp the tube. Care 
must be taken to avoid damage to the balloon.  
 
8. A gastrotomy is made within the innermost 
purse string suture using an electrocautery and 
extended using an artery forceps.  
Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
The serosa and subserosal muscular layers are incised with 
electrocautery, in the center of the inner purse string.  
 
 
A sharp hemostat, rather than continued electrocautery, is used 
to complete entry into the stomach. The operator may feel a 
“pop” as the mucosa and submucosa are breached.  
 
9. The gastrostomy tube is then inserted inside the 
stomach, the balloon is inflated and inner purse 
string suture is tied.  
 
Grasping the side of the gastrotomy gently with forceps, the 
surgeon passes the tube into the lumen of the stomach.  
 
 
The balloon is inflated and the inner purse string is tied.  
 
10. The outer purse string is tied while gentle 
inward pressure is applied to the tube to “bury” 
the inner purse string. The suture is not cut.  
11. The stomach is attached to the abdominal wall 
using the suture of the outer purse string, just to 
the left of where the tube enters the abdominal 
wall. 
Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
The anchoring stitch that is lateral to the tube is the most 
difficult one to see and place. The suture from the outer purse 
string, with the needle still attached, is used. Note that in this 
picture, the clamp in the top of the picture is attached to the 
peritoneum, providing some visualization. If it were grasping 
the fascia, retraction would be more effective.  
 
12. Two or three more stitches can be applied 
circumferentially to complete the attachment of 
the stomach to the abdominal wall.  
 
These sutures are closer to the surgeon and easier to visualize 
with proper retraction.  
 
13. The flange is slid downwards until it is snug but 
not overly tight on the abdominal skin. It is then 
secured to the skin.  
 
The flange is usually adherent to the tube and it remains in 
place after it is pulled down snug to the abdominal wall. If using 
a Foley or Malecot catheter, secure the cather to the skin 
directly, taking care not to tie it too tightly and occlude it.  
 
14. Tube feeds can be begun within a few hours 
after the surgery, starting with small boluses and 
checking the residual amount in the stomach 
before every feed. If the patient has nausea or 
vomiting, the tube can be opened and connected 
to a drainage bag. Before discharge, the patient 
or family are counseled on management of the 
tube including cleaning the skin, flushing with 
water after administering feeds, and applying 
barrier cream if there is leakage and irritation.  
 
Pitfalls 
● Early dislodgement of the tube may result in a 
hole in the stomach that drains freely into the 
peritoneal cavity. The surgeon must be aware of 
this possibility. It is generally acceptable for an 
experienced hand to try to replace any dislodged 
tube, but a contrast study is mandatory before 
using a tube that has fallen out and been replaced 
within two weeks of its placement.  
● Foley catheter balloons can migrate across the 
pylorus and cause gastric outlet obstruction. It is 
tempting to inflate the balloon and rely on a 
suture to prevent this occurrence, but inevitably 
the suture will become dislodged. Conversely, 
not inflating the balloon makes the tube more 
Stamm Gastrostomy 
Gady Barutwanayo, Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
prone to dislodgment. For this reason, Foley 
catheters should be avoided for gastrostomy if 
any other option at all is available.  
● Commercially available open and percutaneous 
gastrostomy tubes include a flange that is cinched 
down on the skin to prevent leakage and secure 
the tube. If this flange is too loose, leakage will 
occur. If it is too tight, necrosis of the skin or 
even of the abdominal wall can occur. Our 
practice is to cinch it down until it is tight, then 
release it 1cm. Full thickness necrosis of the 
abdominal wall leads to gastrocutaneous fistula. 
This is a devastating complication that is best 
avoided by erring on the side of “too loose” 
rather than “too tight.”  
● All gastrostomy tubes will allow some degree of 
leakage around the tube. Proper care of the tube 
includes keeping the skin clean including under 
the flange, assuring proper tightness of the 
flange, and protecting the skin with zinc barrier 
cream if irritation starts to occur. Most skin 
complications will occur after discharge, so the 
patient and family should be taught proper care 
of the tube. Other solutions to persistent leakage 
around the tube include changing the tube to a 
larger size, increasing frequency of feeds while 
decreasing volume, and assessing gastric 
emptying function and treating with prokinetics 
if appropriate. In extreme cases the patient may 
need closure and placement of the tube in another 
part of the stomach, or conversion to Janeway 
gastrostomy.  
● When gastrostomy tubes are no longer needed 
and 
removed, 
the 
tract 
usually 
closes 
spontaneously within 2-5 days at most. When it 
does not close, a gastrocutaneous fistula is 
present. The most common causes of this are 
poor nutrition or distal obstruction. This 
complication can make nutrition difficult, as the 
patient will often voluntarily restrict feeds to 
decrease fistula output, leading to a “vicious 
cycle” in an already malnourished patient. If 
measures to improve the patient’s nutrition do 
not lead to fistula closure, laparotomy and 
closure of the fistula may be required. This is a 
difficult situation. Assess for gastric emptying 
pathology or gastric outlet obstruction. Don’t 
forget to address nutritional status carefully 
before attempting this operation (See Chapter, 
Nutritional Assessment.) 
 
Gady Barutwanayo, MBBS 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
February 2022 
