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Perforated ulcer
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摘要
The description of the technique for perforated ulcer covers all aspects of the surgical procedure used for the management of perforated ulcer and suspected gastroduodenal perforation.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration/exposure, suturing, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration/exposure, suturing, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-04
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Apr 2001;1(04).
URL: http://www.websurg.com/doi-ot02en217.htm
URL: http://www.websurg.com/doi-ot02en217.htm
Perforated ulcer
1. Introduction
Basic principles regarding acute peritonitis are as follows: identification of the etiology of the peritonitis, eradication of the peritoneal source of contamination, and peritoneal lavage and drainage.Classification of the types of peritonitis
- primary peritonitis (bacterial origin, but no visceral perforation): eg, spontaneous, tuberculosis, peritoneal dialysis catheterization;
- secondary peritonitis (bacterial origin with visceral perforation): eg, perforated ulcer, perforated appendicitis, perforated diverticulitis, gangrenous cholecystitis, mesenteric infarction, perforated cancer, Crohn’s disease, ulcerative colitis, gynecological pelviperitonitis, postoperative peritonitis, post-traumatic peritonitis;
- tertiary peritonitis (either fungal or without known pathogens).
The laparoscopic approach offers flexibility by enabling the surgeon to adapt the treatment in case of preoperative diagnostic failure, based on the findings of the exploration and, if needed, to modify the approach. When possible, however, the entire surgical treatment can be performed laparoscopically.
Origins of peritonitis
- appendicular peritonitis; perforated ulcer; post-colonoscopic perforation; biliary peritonitis (gangrenous cholecystitis); perforation of the small intestine (diverticulitis, foreign body, ischemic origin); postoperative peritonitis (post-appendectomy); primary peritonitis; gynecological pelvic peritonitis.
Treatment for perforated ulcer ranges from conservative treatment (Taylor's approach) to radical surgery (vagotomy, gastrectomy). However, with the use of powerful acid-suppressing medication and the eradication of Helicobacter pylori, the need for radical surgery in emergencies has sharply declined. The surgical technique most often used is closure of the perforation combined with extensive peritoneal lavage. This procedure can be performed laparoscopically in 85% of cases, making it possible to avoid a median laparotomy that could lead to wound infection and late eventration.
In case of sepsis, however, the creation of a pneumoperitoneum involves 2 risks:
- hypercapnia: carbon dioxide absorption is increased by peritoneal hyperemia,
- bacteremia: either via translocation or direct bacterial passage through the lymphatics of the diaphragm and the thoracic duct.
Some basic principles must be followed. They include administration of intravenous antibiotic therapy prior to insufflation, maintenance of the intra-abdominal pressure between 8 and 12 mm Hg, and early peritoneal lavage.
2. Anatomy
• Topographical anatomy
1. Liver2. Stomach
3. Lesser omentum
4. Gallbladder
5. Hepatic flexure
6. Greater omentum
7. Duodenum
• Local anatomy
1. Abdominal part of the esophagus2. Fundus
3. Cardia
4. Lesser curvature
5. Greater curvature
6. Body
7. Pre-pyloric antrum
8. Pylorus
9. First part of duodenum
10. Second part of duodenum
11. Third part of duodenum
• Pathological anatomy
• Location
The site of the perforation is:- most commonly on the anterior or superior surface of the first part of the duodenum or the pylorus (more rarely on the pre-pyloric antrum);
- less frequently found in the stomach (lesser curvature, fundus);
- rarely found on the posterior surface of the first part of the duodenum or the stomach.
Duodenal perforation is generally 8 to 10 times more frequent than gastric perforation.
• Acute ulcer
Acute ulcers occur in patients with no history of ulceration in 25% to 30% of cases. They have the shape of a small ring, 5 to 10 mm in diameter, with slightly indurated edges at the level of the anterior or superior surface of the duodenal cap.• Chronic ulcer
The chronic form of gastroduodenal ulceration involves major indurated fibrous scarring and adhesive peri-ulcerous inflammation.• Sizes
In two thirds of cases, perforated duodenal ulcers are 5 mm or less in diameter whereas in 55% of cases, gastric ulcers are over 5 mm in diameter and even more than 10 mm in diameter in 30% of cases.10% to 15% of perforated gastric ulcers are cancerous.
• Pathophysiology
Leakage from an anterior duodenal perforation drains toward the right paracolic gutter and then toward the right subphrenic region, the pelvic cavity, the left gutter, and the left subphrenic region.3. Indications
Indication- suspected gastroduodenal perforation.
Contraindications
- patient with high risk (ASA classification type IV, in a non-reversible state of shock);
- massive ileus;
- limited laparoscopic experience;
- suspected perforated gastric cancer;
- hemodynamic instability secondary to sepsis.
4. Operating room set-up
• Patient
- in supine position,- legs straight and spread out.
The patient is in steep anti-Trendelenburg position at the time of suturing and upper abdominal lavage and in Trendelenburg position during pelvic lavage.
• Team
Patient, surgeon and assistants are in the same position as for laparoscopic cholecystectomy. The surgeon stands between the patient's legs and the assistant stands on the patient's left. During pelvic lavage, the surgeon and the assistant may exchange positions.1. Surgeon
2. Assistant
3. Anesthesiologist
• Equipment
1. Anesthetic unit2. Laparoscopic unit
3. Electrocautery
4. Instrument table
5. Operating table
5. Trocar placement
• Optical
Four trocars are generally necessary. The optical trocar is in supraumbilical position.• Operating
A 5 mm trocar is placed in the right flank (anterior axillary line) for the atraumatic grasper.A 5 or 10/11 mm trocar is placed in the left flank (generally midclavicular line at umbilicus level) for the needle holder, which should be perpendicular to the suture axis (usually the pyloroduodenal axis).
• Retractor
A 5 mm trocar is placed in subxiphoid position for a liver retractor.6. Instrumentation
• Optical devices
A 0° laparoscope is commonly used.A 30° laparoscope is sometimes useful to visualize a perforated superior surface of the duodenum.
• Retracting devices
A suction-irrigation device is recommended for peritoneal lavage.7. Major principles
- anesthetic monitoring (cardiac monitor, capnograph, arterial blood pressure, assisted ventilation);- intravenous antibiotic therapy before insufflation;
- pneumoperitoneum: intra-abdominal pressure (CO2 between 8 and 12 mm Hg);
- localization and drainage of purulent collections (bacteriologic sampling and assessment of peritonitis, either local or general);
- initial peritoneal lavage with physiological solution;
- identification and exposure of the contamination source (perforated ulcer);
- biopsy performed in case of gastric ulcer;
- suturing the ulcer;
- drainage of the peritoneal cavity according to the surgeon's preference.
8. Exploration/exposure
• Exposure
The presence of a perforated ulcer must be verified once the inferior surface of the left lobe of the liver has been retracted (segments III and IV).Tips: in case of difficulty, a 30° laparoscope should be used and a methylene blue test or a test with air injected via the gastric tube can be performed. The opening of the omental bursa (lesser sac) via the inferior part of the lesser omentum or possibly the gastrocolic ligament remains an option.
• Searching for pus
• Tilt of the table
The localization of purulent collections and the extent of peritonitis must be assessed. The tilt of the operating table should be adapted if necessary.• Left lateral supine position
In the right paracolic gutter• Steep table position
In the right and left subphrenic regions• Trendelenburg position
In the pelvic cavity, the rectouterine pouch (Douglas' pouch) and between the intestinal loops• Right lateral supine position
In the left paracolic gutter9. Suturing
• Principles
The most common technique is based on the application of standard stitches to the perforation using intracorporeal knots.Other options include the use of biological glue and sponge plug as a plasty with the round ligament.
• Biopsy
A biopsy of duodenal ulcers should not be performed. However, in gastric ulcers, several samples of the gastric wall should be taken at the level of the perforation for histological examination.• Suturing
- slowly absorbable sutures or non-absorbable sutures (2/0 or 3/0);- transverse suturing with focus on the pyloroduodenal axis in case of duodenal ulcer;
- interrupted sutures.
• Variations
• Optional
Omentoplasty: once the ulcer is sutured, a loose edge of the greater omentum is fixed over the suture line using, for example, the upper thread that was left loose after making the knot.• Difficulty
In chronic ulcers of the callous, cardboard-like type, it is hard to approximate the edges of the ulcer. Woven sutures of bigger caliber (0 or 1) must sometimes be used in order to avoid cutting the bowel wall. If the surgeon is concerned about the integrity of the repairs, a methylene blue test or a test with air injected via the nasogastric tube can be performed.• Danger
It is important to prevent sutures from causing stenosis at the pyloroduodenal level, notably in the presence of ''old chronic ulcers''. If needed, a gastroscopy performed during the procedure makes it possible to rule out this complication.• Graham patch
In the US, surgeons generally favor not suturing the perforation because of the risk of tearing the acutely inflamed tissues. The most common procedure in the US is called Graham patch, whereby a piece of omentum is used to patch the perforation. The perforation is not sutured. The omental patch is sutured with 2-0 or 3-0 sutures to the healthy edges of the bowel away from the perforation.10. End of procedure
• Principles
The lavage of the abdominal cavity is an essential step in the procedure. It begins right after the exploration to rapidly remove most of the contaminated liquids. It is continued after suturing.• Lavage
Peritoneal lavage is performed with warm physiological solution (4 to 6 L), using a pressured suction-irrigation device, until a clear effluent is obtained. It is often necessary to change the position of the operating table or even to moderately shake the patient in order to have good distribution of the liquid throughout the peritoneum. All residual liquid must be aspirated.• Drainage
Routine drainage of the peritoneal cavity is performed using silicone drains (from 12 to 18 French).Depending on the severity of peritonitis, 1 to 3 drains are applied: one drain to the sutured ulcer exiting via the trocar site situated on the right flank, another drain at the level of the rectouterine pouch exiting via the trocar site situated on the left flank and a left subphrenic drain exiting via the subxiphoid trocar site. Drainage is performed in Trendelenburg position.
• Closure
Trocars are removed one after the other and hemostasis of the trocar sites is checked. The musculo-aponeurotic plane is only closed at the level of the 10/11 mm trocar sites. The skin is closed using staples or sutures.11. Postoperative management
Intravenous H2 receptor antagonists or proton pump inhibitors are administered orally once infusions are stopped.Drains are removed once the effluent is less than 100mL per day, provided it is not draining feculent, bloody or purulent material.
The nasogastric tube is removed once peristalsis resumes and a clamping test is successful. Water-soluble gastroesophageal contrast examination is then performed to check the integrity of the closure and ensure the absence of pyloroduodenal stenosis. Food intake is then restored.
When suturing is difficult or bowel function is resumed late, the gastric tube may be left in place longer.
Intravenous antibiotic therapy is maintained depending on the severity of the ulcer and at least until a culture of the pus taken during the procedure is obtained. If the culture is positive, intravenous antibiotic therapy is continued for 10 days first and then orally after return of bowel function and food intake.
Follow-up gastroscopy is generally performed 4 to 6 weeks after the procedure.
12. Reference
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