Technique for laparoscopic gastrostomy button placement for type A esophageal atresia with immediate gap analysis

Purpose: Patients with pure esophageal atresia (Type A) are typically managed with staged surgical intervention, however timing of surgical correction and outcome vary with gap length. We propose a modified technique and order of operation to initially establish enteral access and assess gap length though a minimally invasive approach in this patient population that commonly has microgastria. Operative Technique: We propose a modified operative approach for pure EA and demonstrate its success in a patient. In our approach, a laparoscopic gastrostomy tube is placed and immediate gap analysis performed at the index operation. Our patient is a 1-day-old 2.6 kg male born at 35 weeks with pure esophageal atresia. In the operation, the abdomen was entered laparoscopically. After lowering insufflation pressure, the stomach was exteriorized and secured to the fascia in four quadrants. The stomach was entered using an introducer needle and fluoroscopic dye was subsequently administered to confirm safe entry in the absence of gastric insufflation. A balloon gastrostomy was passed into the stomach using the Seldinger technique. A grasper was used to compress the pylorus while flushing additional contrast through the gastrostomy tube to assess gap length. The grasper was then relaxed to show contrast passing into the duodenum and ruling out a gastric outlet obstruction from the balloon. Conclusion: This technique allows for laparoscopic gastrostomy button placement with immediate gap analysis in a patient with pure esophageal atresia.