Alternative laparoscopic management of perforated peptic ulcers

Abstract

Surgery--namely, suture closure-is still the treatment of choice for perforated peptic ulcers, despite the proven efficacy of Taylor's conservative approach. Such conservative management, however, has been proven less effective in high-risk patients and those with perforations more than 12 h old. Here we suggest alternative laparoscopic treatments for perforated peptic ulcers. We have treated laparoscopically six patients (one F, five M; mean age 57.6 years; range 31-81 years); the mean duration of the operation was 52 min; the median hospital stay was 7 days (6-15 days); H2-blockers, antibiotics, and fluids were administered in the p.o. course; the follow-ups range from 6 to 18 months. On the basis of our experience, the treatment of choice for perforated peptic ulcers is Taylor's conservative procedure and laparoscopic drainage of the abdominal cavity when there is mild peritoneal reaction (usually less than 6 h from the onset of perforation). In case of remarkable peritonitis (usually more than 12 h), it is mandatory to add an accurate lavage. When the site of perforation is concealed by the peritoneal inflammation it should not be searched; when visible, it might be obliterated with the round ligament or an omental tissue strand, particularly if larger than 1 cm in diameter.

Laparoscopic repair of perforated duodenal ulcer

“…Lavage is an adequate measure to counteract the negative effects of peritonitis, which form the major cause of morbidity and mortality in these patients. Some investigators [32] even obtained very satisfactory results performing only laparoscopic lavage and drainage in combination with a conservative Taylor method, confirming the earlier-reported important role of lavage in the perforation management [11]. Our 100-patient series matches favorably with the Hong Kong consecutive series of 100 cases operated by means of either omental patch repair (n ‫ס‬ 44) or suture patch repair (n ‫ס‬ 35) or fibrin glue repair (n ‫ס‬ 21) [25].…”

Does laparoscopy increase bacteremia and endotoxemia in a peritonitis model?

“…It has been demonstrated in prospective randomized trials that laparoscopic appendectomy is superior or at least does not differ compared to open appendectomy in terms of postoperative complications, hospital stay, and recovery [1,11]. Urbano et al further demonstrated that laparoscopic surgery of perforated peptic ulcers is simple, rapid, and followed by a quick recovery [13]. In contrast to these results, Eypasch et al reported higher morbidity after laparoscopic treatment of perforated peptic ulcer than after a conventional approach [5].…”

“…Some authors reported successful treatment of inflammatory processes like appendicitis, Crohn's disease, perforated peptic ulcer, or diverticular disease [1,3,9,11,13]. Furthermore, laparoscopic surgery appears to be feasible in patients with abdominal sepsis without increasing postoperative morbidity and mortality [6].…”

Laparoscopic repair of perforated gastroduodenal ulcer by running suture

“…If the ulcer is already covered by omentum, the authors generally restrict themselves to peritoneal drainage and lavage, since they consider it the most important part of any intervention. Other techniques of ulcer repair are: suturing with single stitches [8,30], closure with gelatine sponges and fibrin glue [11,12], sutured or stapled omental patch repair [10,11,12,17,18,21,22,23,24,26,27] and gastroscopyaided insertion of the ligamentum teres hepatis or omental plug [19,20].…”

“…There is still, however, disagreement as to the relative merits of laparoscopic ulcer repair. Laparoscopic techniques such as omental patch repair, gelatine sponge, fibrin glue [11,12] and gastroscopy-assisted methods [19,20] are time consuming and require extended surgical skills with respect to suturing and knotting techniques [5,11,12,18,19,21,22,23,24,25,26,27].…”