Chapter 12 Laparoscopic Repair of Perforated Peptic Ulcer

Dennis C.T. Wong

The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.

The overall incidence of peptic ulcer disease has declined significantly over the past few decades owing to the introduction of histamine-2 receptor blockers in the 1970s and proton pump inhibitors in the 1990s. The successful treatment of Helicobacter pylori also played an important role in its decline, and studies have shown that ulcer recurrence after treatment is low. Despite these dramatic epidemiologic changes, the incidence of complications arising from peptic ulcer disease has not declined. In fact, perforated peptic ulcer has been on an increasing trend, particularly in elderly people, with the popularized use of nonsteroidal anti-inflammatory agents being the most likely culprit. The importance of ulcer perforation cannot be underestimated because it is associated with major morbidity and accounts for more than 70% of all peptic ulcer mortality. It is the second most common perforated viscus following perforated appendicitis.

Currently, perforated peptic ulcers can be effectively treated with simple closure with omental patch without the need for additional procedures for acid reduction. This is the result of the effective medical treatment using proton pump inhibitors together with complete eradication of H. pylori. Compared with traditional treatment by Graham-Steele patch closure or gastrectomy, this is a straightforward procedure that is ideally performed using minimally invasive techniques. The first laparoscopic suture repair of duodenal ulcer perforation was reported in 1990, and this procedure has been widely adopted since. Our institution first reported the technique of laparoscopic single-stitch omental patch repair in 1997, and the technique has been routinely practiced since 2004. Our experience has shown that this technique is safe and reliable.

Operative indications

All perforated peptic ulcers warrant immediate treatment. Most should be treated with urgent surgery. We recommend the routine use of laparoscopy for all cases of suspected perforated peptic ulcer that present with typical history of sudden-onset epigastric pain and signs of generalized peritonitis. In the absence of free air under the diaphragm (about 30%), an urgent abdominal computed tomography scan may be performed to exclude other causes of acute abdomen. Cases in which laparoscopy may not be considered include patients with previous abdominal surgeries, clinical evidence of concomitant bleeding ulcer, or gastric outlet obstruction. These patients should undergo conventional repair by upper midline laparotomy. Iatrogenic (following endoscopic procedures) ulcer perforation is not an absolute contraindication to laparoscopic repair but should be performed with caution because these perforations tend to be quite sizeable and difficult to treat with omental patch alone, and open conversion is often necessary. Other indications for conversion to an open procedure are unidentifiable site of perforation, nonpyloroduodenal perforation, perforation larger than 10 mm, and technically difficult repair. There is controversy about whether patients with a clinically sealed-off perforated ulcer should receive surgery because there is evidence suggesting that conservative management can be successful. The diagnosis of sealed-off perforation should be suspected if the patient does not present with severe sepsis or generalized peritonitis and there is no extravasation of contrast during radiologic upper gastrointestinal studies. When conservative treatment is chosen, the patient must be closely monitored. A low threshold for immediate laparoscopy is warranted if the patient’s condition changes.

Preoperative evaluation, testing, and preparation

Perforated peptic ulcer is a surgical emergency and operation should be swiftly arranged to reduce morbidity and mortality. A thorough preoperative assessment by an experienced anesthetist is essential. The general assessment should include the American Society of Anesthesiology classification status. Any existing electrolyte imbalance should be corrected.

Preoperatively, the patients are kept NPO, and a nasogastric tube is inserted to reduce further peritoneal contamination. They are started empirically on a second-generation cephalosporin (ciprofloxacin if penicillin allergy) and intravenous proton pump inhibitor. Patients with risk for thromboembolic events should also receive prophylactic anticoagulation, usually low-molecular-weight heparin given intramuscularly.

Informed consent should include explanation of risks of surgery in general, but more specifically, surgeons should mention the rate of open conversion (about 30%), morbidity rate (about 25%), and overall mortality rate (about 10%). The need for postoperative intensive care unit admission should be anticipated for patients who are elderly, are hemodynamically unstable, or have multiple medical comorbidities.

Patient positioning

The patient is placed in the modified lithotomy (Lloyd-Davies) position. The surgeon stands between the patient’s legs and the assistant on patient’s right side, with the monitors positioned on either side of the head of the table (Fig. 12-1). Care is taken to ensure that all pressure points are adequately padded.

FIGURE 12-1 Operating room setup for laparoscopic repair of perforated peptic ulcer. The patient is in the modified lithotomy position with operating surgeon adopting the French position and assistant on patient’s right side.

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