The pull technique for PEG placement can be performed using a one operator and one nurse/technician assistant approach. The patient should be positioned supine with supplemental oxygen and monitoring devices in place. A diagram of patient, operator, and assistant positioning is presented (Fig. 2.2). The abdomen should be generously prepped and draped as the safe window of PEG placement is not always strictly in the left upper quadrant—it can be epigastric and rarely even just to right of the patient’s midline. The PEG kit and associated equipment should then be opened and ready. Many commercial vendors provide different versions of these kits and not every kit will have everything needed. If the kit is anticipated to provide for everything including an endoscopic snare, scissors, etc., then this must be checked and ensured prior to starting the procedure. After the appropriate administration of conscious sedation or monitored anesthesia care, the operator introduces a flexible upper endoscope into the esophagus and a brief, standard EGD examination is performed. After ensuring no unexpected pathology, insufflation of the gastric body is provided sufficient to efface the rugal folds.

At this point, the crux of the procedure is finding the safe window for tube placement. There are three evaluations which should routinely be conducted to ensure such a safe window is found prior to PEG placement.

Authorities have traditionally used the lack of transillumination during this procedure as a contraindication for completing the PEG procedure as planned. If however there is good 1:1 palpation and the safe track is negative for any bubbles prior to entry into the gastric lumen at the site, there are series which have demonstrated the safety of completing the procedure as planned in this setting. Thus at least two of these three criteria must be found to establish the safe window for PEG placement.

An endoscopic snare is then passed through the endoscope and is left waiting in the gastric lumen. With this done, a 1 cm incision is made through skin at the selected site. A catheter is passed through the incision along the same trajectory as the 1:1 palpation and aspiration anesthetic needle into the stomach lumen. The snare is used to encircle the catheter thus securing it. The operator passes the looped wire through the catheter into the gastric lumen, taking care to orient it properly. The snare is then moved from where it is secured on the catheter to the wire. Once the snare is securely around the wire, the entire endoscope along with snare and wire are removed from the patient’s mouth. The wire is then freed from the endoscope channel and secured to the tip of the PEG tube. The wire is then pulled (thus PULL technique) at the level of the abdominal wall, bringing the wire and the now secured tip of the PEG tube completely out of the patient until gentle traction or resistance is felt as the inner flange abuts the gastric wall (Fig. 2.5). Once positioned, an outer flange is placed down the tube (typically resting at 2–4 cm on the skin of a normal body habitus patient), the wire and some of the excess length of tubing is cut free and the cap is applied. At this point, a repeat endoscopic evaluation may be performed to ensure the inner flange is sitting without undue tension and no bleeding is visualized.