A gastrotomy is a surgical incision through the wall of the stomach, performed to access the organ’s interior for removing foreign objects, excising tumors, or creating openings for feeding tubes. The procedure has been documented since 1602 and remains one of surgery’s more reliable operations, with a remarkably low complication rate when the stomach wall is closed properly. Despite advances in endoscopy that have reduced the need for gastrotomy in many situations, there are still cases where opening the stomach surgically is the safest or only realistic option.
Why a Gastrotomy Is Performed
The most common reason is the removal of something that should not be in the stomach and cannot be pulled out with an endoscope. Large or sharp foreign bodies that become lodged in the stomach pose real danger: they can perforate the wall, cause bleeding, or obstruct the passage into the small intestine. A retrospective study of 542 cases of ingested foreign bodies found that while the vast majority passed on their own or were removed endoscopically, about 5% required surgery. Among those surgical cases, roughly a third involved large objects sitting in the stomach with no tendency to move further along, and those were removed through gastrotomy.1PubMed. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases Sharp objects carry an additional risk of perforation and are generally recommended for removal rather than watchful waiting.2PubMed Central. Laparoscopic removal of large and sharp foreign bodies from the stomach
Gastrotomy is also used to remove bezoars, which are masses of indigestible material that accumulate in the stomach over time. The most dramatic version is a trichobezoar, a compacted ball of swallowed hair sometimes seen in people with trichotillomania (compulsive hair pulling) who also swallow the hair. In extreme cases called Rapunzel syndrome, the hair mass fills the entire stomach and sends a long tail through the pylorus into the small intestine. These masses are far too large and tangled for endoscopic retrieval and require open surgery with a gastrotomy incision to extract them.3PubMed Central. Recurrent Rapunzel syndrome – A rare tale of a hairy tail In one reported case, the trichobezoar was removed through an anterior gastrotomy after exploratory laparotomy, with no evidence of stomach wall death or infection.4International Journal of Surgery Case Reports. Rapunzel syndrome due to ingested hair extensions: Surgical and psychiatric considerations
Beyond foreign body removal, gastrotomy plays a role in gastrostomy tube placement, where a permanent opening is created from the skin surface into the stomach for long-term feeding. Surgeons also use gastrotomy to access and resect submucosal tumors growing within the stomach wall, particularly when the tumor sits near the junction of the esophagus and stomach and is difficult to reach from outside.
A Surprisingly Old Operation
Gastrotomy has deeper historical roots than most people would guess. An 1898 review in JAMA documented that the first gastrotomy for foreign body removal was performed in 1602, meaning surgeons were opening stomachs more than a century before germ theory existed. Between 1602 and 1887, only 35 cases were recorded, but even in this pre-antiseptic era the operation was surprisingly survivable: only five of those 35 patients died. After 1887, as antiseptic and aseptic techniques took hold, an additional 22 cases were reported in just over a decade, reflecting growing confidence in the procedure.5JAMA. GASTROTOMY FOR THE REMOVAL OF FOREIGN BODIES IN THE STOMACH The stomach’s rich blood supply and thick, muscular wall likely contributed to its resilience, even under primitive surgical conditions.
Open, Laparoscopic, and Intragastric Approaches
A traditional open gastrotomy involves a midline or upper abdominal incision large enough for the surgeon to directly see and handle the stomach. This remains the standard approach when the object being removed is very large, when there is concern about contamination or perforation, or in emergency settings where speed matters.
Laparoscopic gastrotomy uses several small incisions and a camera to perform the same operation with less trauma to the abdominal wall. The trade-off is a longer time in the operating room. Sharp or large foreign bodies have been successfully removed laparoscopically, and the approach generally offers faster recovery and less postoperative pain.6PubMed Central. Laparoscopic removal of large and sharp foreign bodies from the stomach
An even more specialized option is intragastric surgery, where instruments are passed through a single small incision directly into the stomach to operate on lesions from inside. A report of four patients undergoing single-incision laparoscopic intragastric surgery for tumors near the esophagogastric junction found median operative times around two and a half hours with minimal blood loss, and none of the cases needed conversion to open surgery.7PubMed. Single-Incision Laparoscopic Intragastric Surgery for Gastric Submucosal Tumor Located Adjacent to Esophagogastric Junction This approach is reserved for specific tumor locations where working from inside the stomach gives the surgeon the best angle to remove the growth while preserving the surrounding normal tissue.
How the Stomach Is Closed
After the gastrotomy has served its purpose, closing the incision properly is the most critical step. The stomach wall has multiple layers, and the closure usually involves at least two layers of sutures. The submucosa, a strong connective tissue layer, is where most of the holding strength resides. Surgeons typically close the inner layer (mucosa and submucosa) first, then place a second layer of sutures through the muscle and outer serosal coat.
Research into the best closure pattern has tested variations of this two-layer approach. One canine study compared four different techniques, including simple continuous patterns, inverting patterns, combinations of both, and even the use of skin staplers for the outer layer.8Journal of Advanced Veterinary Research. Comparison of Four Gastrotomy Closure Techniques in Dogs In gastrointestinal surgery more broadly, stapled closures and anastomoses tend to shorten operating time compared to hand-sewn techniques.9PubMed Central. Comparative Study between Staplers and Conventional(Hand-Sewn) Anastomosis in Gastrointestinal Surgery A large Chinese study comparing stapled and hand-sewn approaches in gastric cancer surgery found that staplers reduced operating time, sped recovery of gut function, and lowered rates of bleeding at the connection site, though both approaches performed similarly for some other complications.10PubMed Central. Comparison of hand-sewn and stapled anastomoses in surgeries of gastrointestinal tumors based on clinical practice of China
The stomach’s blood supply makes it a forgiving organ to close. Its arterial network has built-in redundancy: the left and right gastric arteries supply the lesser curve, the gastroepiploic arteries feed the greater curve, and short gastric arteries reach the fundus. These vessels frequently show anatomical variations in their origins and branching, but the overlap means that even when one vessel is compromised, the surrounding tissue generally receives enough blood to heal well.11PubMed Central. The Blood Supply of the Stomach: Anatomical and Surgical Considerations
Complications and Dehiscence
The complication surgeons worry about most after gastrotomy is dehiscence, meaning the closure breaks down and stomach contents leak into the abdominal cavity. This can cause peritonitis, a life-threatening infection. The good news is that gastrotomy dehiscence is rare. A study examining dehiscence rates in dogs and cats after gastrotomy for foreign body removal found no confirmed cases of the incision falling apart. Two animals developed septic peritonitis and were euthanized before surgeons could confirm the source, so gastrotomy dehiscence could not be ruled out, but even assuming both were caused by closure failure, the rate was under 1%.12PubMed. Dehiscence rate and associated risk factors after gastrotomy for removal of foreign material in dogs and cats
While that study focused on animals, human gastrotomy similarly benefits from the stomach’s rich blood supply and thick muscular wall. Intestinal surgery generally carries a higher leak risk than stomach surgery because the intestinal wall is thinner and its blood supply less generous. The combination of robust vasculature and layered tissue makes the stomach one of the more reliable parts of the gastrointestinal tract to cut and sew back together.
The Role of Antibiotics
Prophylactic antibiotics before a gastrotomy-related procedure are now considered standard. For gastrostomy tube placement, a Cochrane review pooling over 1,200 patients from 12 randomized trials demonstrated a significant reduction in peristomal infection when antibiotics were given beforehand. Cefazolin, a first-generation cephalosporin given within 30 to 60 minutes before the incision, is the preferred agent.13Trauma Surgery & Acute Care Open. Surgical and procedural antibiotic prophylaxis in the surgical ICU A separate randomized trial looking specifically at percutaneous gastrostomy found that prophylactic antibiotics reduced early peristomal infection from about 13% to 0% in the per-protocol analysis.14PubMed. Value of Antibiotic Prophylaxis for Percutaneous Gastrostomy: A Double-Blind Randomized Trial Another prospective trial reached the same conclusion, recommending antibiotics as a general measure for percutaneous endoscopic gastrostomy.15PubMed. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial
One less obvious consideration is stomach acid itself. A study examining the impact of proton-pump inhibitors on peritoneal contamination after gastrotomy found that suppressing stomach acid with these drugs actually increased the rate of bacterial contamination and abscess formation when stomach contents leaked into the abdominal cavity. The naturally acidic environment of the stomach appears to serve as a protective barrier against infection during and after the procedure.16PubMed. The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures This is an interesting wrinkle for patients already on acid-suppressing medications for unrelated reasons, though it does not necessarily mean those medications should be stopped before surgery.
Pain Control After Surgery
Pain management after any surgery that involves opening the stomach or upper abdomen has moved away from relying solely on intravenous opioids. A randomized trial of patients undergoing gastric bypass compared three strategies: wound infiltration with local anesthetic plus patient-controlled intravenous analgesia, epidural anesthesia and analgesia, or patient-controlled intravenous analgesia alone. Patients who received local wound infiltration as part of a multimodal approach had pain scores that, in a subset of responders, were lower at several time points than even the epidural group, while avoiding the hemodynamic effects associated with epidurals.17Anesthesia & Analgesia. A Comparison of Multimodal Perioperative Analgesia to Epidural Pain Management After Gastric Bypass Surgery
A study of open gastrectomy patients compared continuous wound infiltration (a catheter dripping local anesthetic directly into the incision site) against epidural analgesia and standard patient-controlled intravenous morphine. Both the wound infiltration and epidural groups used less morphine, had less nausea and vomiting, recovered bowel function sooner, and went home roughly two days earlier than the intravenous-only group. Pain scores during the first 48 hours were similar across all three groups, suggesting that multimodal approaches achieve equivalent pain relief with fewer side effects.18PubMed Central. Effectiveness and safety of continuous wound infiltration for postoperative pain management after open gastrectomy The practical upshot is that patients facing stomach surgery today have options beyond the traditional epidural-or-nothing choice, and local wound infiltration appears to offer a simpler, lower-risk alternative that works about as well.
Eating Again After Stomach Surgery
Historically, surgeons kept patients nil by mouth for days after any operation involving the stomach, waiting for clear signs that the gut was working again before allowing oral intake. That practice has been challenged by growing evidence favoring earlier feeding. A systematic review and meta-analysis comparing early versus delayed oral feeding after gastrectomy found that early feeding shortened hospital stays by about a day and a half without increasing complications or feeding intolerance.19PubMed. Early versus delayed oral feeding after gastrectomy for gastric cancer: A systematic review and meta-analysis Early feeding also led to quicker return of bowel function and better nutritional markers like albumin and prealbumin levels.
A more recent meta-analysis focused on laparoscopic total gastrectomy confirmed these findings: early oral feeding reduced hospital stay by almost two days and time to first passage of gas by about a day, again with no increase in complications.20PubMed Central. Early oral feeding after laparoscopic total gastrectomy in gastric cancer patients: a meta-analysis of randomized controlled trials and cohort studies A retrospective study of 353 patients after total gastrectomy similarly found that early feeding did not increase the risk of anastomotic failure, and there was a trend toward fewer surgical and general complications in the early feeding group.21Journal of Gastrointestinal Surgery. Feasibility, Safety, and Clinical Benefit of Early Oral Feeding After Total Gastrectomy for Cancer
For a straightforward gastrotomy, as opposed to a more extensive gastric resection, recovery is generally faster because the stomach’s structure and capacity remain intact. The incision heals through the same cascade that repairs tissue elsewhere in the body, but the gastrointestinal tract has the additional advantage of rapid mucosal turnover. The stomach lining regenerates quickly, which is one reason the organ tolerates surgical insult relatively well.
When Endoscopy Replaces Surgery
For most foreign bodies that make it to the stomach, endoscopy is the first-line approach. A flexible scope passed through the mouth can grab and retrieve coins, button batteries, small bones, and many other objects without any incision at all. Gastrotomy becomes necessary when the object is too large to fit back through the esophagus, too sharp to safely drag through the upper digestive tract, or has become embedded in the stomach wall.
An interesting middle ground exists in veterinary surgery, where foreign bodies in dogs and cats sometimes lodge in the intestine rather than the stomach. A study comparing orogastric retrieval (manipulating the object back into the stomach and pulling it out through the mouth via endoscopic tools) against gastrotomy found no differences in complication rates, time to first meal, or time to discharge. The gastrotomy group took about 12 minutes longer in surgery.22PubMed. Comparison of removal of intestinal foreign bodies using orogastric retrieval techniques versus gastrotomies in dogs and cats The results suggest that when an object can be milked back into the stomach from the intestine, retrieving it through the mouth is slightly faster but otherwise equivalent to cutting the stomach open. In practice, the choice often depends on what equipment is available and the surgeon’s comfort level.
Gastrotomy in Veterinary Medicine
Veterinarians perform gastrotomies far more often than human surgeons do, for the simple reason that dogs eat things they should not with extraordinary regularity. Socks, rubber balls, corn cobs, fish hooks, children’s toys, and fragments of bone are routine finds. The surgical principles are the same: make a controlled incision in an avascular area of the stomach wall (typically the ventral body, between the greater and lesser curvatures), remove the offending item, and close in two layers.
The low dehiscence rate discussed earlier comes from veterinary data, but veterinary gastrotomy also provides a useful window into how the procedure performs across a wide range of body sizes and conditions. From a 3-kilogram cat to a 60-kilogram Great Dane, the technique scales well. One particularly unusual case involved a gastrotomy performed on a blue catfish to remove an embedded fishhook, making it the first documented gastrotomy in a bony fish. The fish recovered fully, though it did experience skin incision dehiscence six weeks later that healed on its own.23Veterinary Record Case Reports. Gastrotomy for removal of a gastric fishhook foreign body in a blue catfish (Ictalurus furcatus) It is hard to think of a better testament to the stomach’s willingness to heal than the fact that even a fish stomach can be cut open and sutured shut with a good outcome.