Mutter D, Navez B. Perforated duodenal ulcers: laparoscopic treatment. Epublication: WeBSurg.com, Sept 2004;4(9). URL: http://www.websurg.com/ref/doi-vd01en1102e.htm

Perforated duodenal ulcers: laparoscopic treatment

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Générale et digestive > Estomac et duodénum > Ulcère gastro-duodénal > Ulcère perforé

D Mutter (France), B Navez (Belgium)

September 2004

English - 05'00''

This video demonstrates an emergency surgery in a patient with perforated anterior duodenal ulcer. The abdominal cavity is inspected, a bacteriological culture obtained, and the cavity is lavaged. An anterior perforation is identified and repaired directly with absorbable suture. An omental patch is applied. The alternative is application of fibrin glue.

Keywords: emergency,operation,perforated duodenal ulcer

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00'17''

Case presentation
The operator is at the left side of the patient, the assistant stands opposite the operator and the monitor is in the right hypochondrium. Four trocars are used. A 10mm umbilical trocar is used for the camera and 5mm trocar is for the operating instruments.
The 1st step of the operation is the exploration of the abdominal cavity, which allows to confirm the diagnosis of generalized peritonitis. In addition, it allows to differentiate between the septic and the clinical peritonitis, and especially it permits to determine the feasibility of the laparoscopic repair.
Peritoneal fluid is obtained and sent for bacteriological analysis.
A very important step of the operation is the aspiration of peritoneal fluid, which should be as complete as possible. This is followed by extensive irrigation of the abdominal cavity.
The next step is the exact localization of the perforation, which sometimes may be covered by the liver, gallbladder or omentum. In this case, the perforation is identified on the anterior aspect of the duodenum.
Ideal repair of the perforation is direct closure by absorbable or non-absorbable sutures. Despite a randomized study reported in Annals of Surgery in 1996 by Law has demonstrated that there is no significant difference in clinical evolution between closure and simple lavage of the abdominal cavity, we prefer to perform suture of the perforation to minimize contamination.
Intracorporeal suturing techniques can be used for laparoscopic repair of perforated ulcers as shown in this case.
Intracorporeal suturing allows perfect closure of the opening.
Treatment of perforation may include also an epiploplasty in addition to the closure of the opening, in this case, in addition to the suture as shown here. An omental flap is chosen and is placed over the suture and fixed with 1 or 2 absorbable stitches.
The operation is completed by an extensive abdominal irrigation, which should include at least 3 litres of saline solution. The irrigation should be performed in all abdominal quadrants.
When a reliable direct suture of the opening cannot be achieved, closure can be completed by application of biological glue.
Some surgeons, however, suggest routine use of biological glue for repair of perforated ulcers.
At the end of the operation, we use drain at the operative site.