Journal of Visceral Surgery (2016) 153, 127—133

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SURGICAL TECHNIQUE

Laparoscopic surgical technique for

perforated duodenal ulcer
L. Rebibo ∗, I. Darmon , J.M. Regimbeau

CHU Amiens, 80054 Amiens cedex, France

Available online 10 March 2016

Introduction
Perforation is a complication of duodenal ulcer that occurs in 2—11% of cases [1]. The
perforation typically occurs on the anterior aspect of the duodenal bulb [2]. The principal
etiologies for duodenal ulcer are Helicobacter pylori infection and ingestion of nonsteroidal
anti-inflammatory drugs (NSAIDs) [3].
Currently, management of perforated duodenal ulcer is most commonly performed via
a laparoscopic approach. This has not been associated with any increase in the risk of
postoperative complications (intra-abdominal or pulmonary), and it reduces postopera-
tive pain and analgesic requirements [4]. Conversion to open surgery is necessary in only
8% of cases [5]. The principal reasons for conversion are a large perforation > 6 mm, fragility
of the duodenal edges, and associated bleeding or septic shock [5]. The Boey score allows
selection of patients whose condition favors a laparoscopic approach, based on three pre-
dictive criteria for postoperative mortality: a systolic blood pressure < 90 mmHg, duration
of symptoms > 24 hours, and an ASA score ≥ 3 [6]. If all three criteria are present, the post-
operative mortality exceeds 50% [7] and should be a contra-indication for laparoscopic
management [8]. The surgical technique consists of lavage of the peritoneal cavity after
collection of fluid for bacterial and fungal culture, followed by closure of the perforation
defect with sutures and an on-lay omental patch, and finally drainage of the operative site
[9].

∗ Corresponding author.
E-mail address: l.rebibo@hotmail.fr (L. Rebibo).

http://dx.doi.org/10.1016/j.jviscsurg.2016.02.004
1878-7886/© 2016 Elsevier Masson SAS. All rights reserved.
128 L. Rebibo et al.

1 Patient positioning
The patient is positioned supine with arms and legs abducted and the table tilted to 30% of reverse Trendelenburg.
The surgeon stands between the patient’s legs with the first assistant to the right. The monitor is positioned above the
patient’s right shoulder.
Laparoscopic surgical technique for perforated duodenal ulcer 129

2 Trocar position
The initial step is insertion of a 10 mm trocar just
above the umbilicus by the open Hassan technique. Then
a 5 mm trocar is inserted through the right rectus muscle
and a 10 mm trocar through the left rectus muscle under
direct laparoscopic vision. An additional 5 mm trocar may be
placed in the left subcostal region based on intra-operative
findings (i.e., large left hepatic lobe falling down over the
duodenum and obscuring exposure of the operative field).

3 peritoneal
Exploration and lavage of the
cavity
If initial exploration reveals peritonitis, bacteriologic and
fungal cultures are taken [10]. The peritoneal cavity is
then copiously lavaged, taking care to remove any false
membranes, particularly from the anterior surface of the
duodenum, in order to visualize the perforation.
130 L. Rebibo et al.

4 Blue dye test

The perforation is typically located on the anterior
surface of the duodenum. If the site of perforation is not
immediately evident, the surgeon should occlude the second
portion of the duodenum with an atraumatic laparoscopic
bowel clamp while the anesthetist is requested to introduce
a naso-gastric tube and instill methylene blue. If instilla-
tion of blue dye fails to identify the site of perforation,
instillation of intragastric air may identify the perforation.

5 Suture closure of the perforation

After identification of the duodenal perforation, a
laparoscopic needle holder is introduced through the 10 mm
left trans-rectus trocar and a grasping forceps through the
5 mm right trans-rectus trocar, allowing placement of one to
three figure-of-eight sutures using 3-0 synthetic absorbable
sutures, depending on the size of the orifice to be closed.
There is no indication to biopsy the margins of the per-
foration, since the incidence of duodenal malignancy is
essentially zero in patients with perforated duodenal ulcer.
The suture ends are left long within the abdominal cavity
with the needles carefully positioned on the greater omen-
tum to avoid injury to nearby abdominal organs such as the
duodenum or bile duct. A methylene blue test is once again
performed to confirm that the duodenal closure is water-
tight.
Laparoscopic surgical technique for perforated duodenal ulcer 131

6 Omental patch
The sutures that were left long within the abdominal
cavity are now recovered and used to anchor the omental
patch in place. A mobile portion of the greater omentum
is sought and mobilized, taking care to avoid tension as
it is sutured down to reinforce the duodenal suture line.
Placement of an omental patch decreases the risk of duo-
denal fistula from the duodenal closure [11]. Several types
of omental patch have been proposed including either a
pediculized patch covering the suture or a pedicled omen-
toplasty plugged into the perforation [12,13].
132 L. Rebibo et al.

7 Drain placement
The abdominal cavity is once again lavaged and then
a suction drain is introduced through the right trans-rectus
trocar site to allow for both aspiration and ongoing lavage.
The tip of the drain is placed adjacent to the omental patch.
Laparoscopic surgical technique for perforated duodenal ulcer
Postoperative management
There are no specific recommendations regarding postop-
erative management of patients with perforated duodenal
ulcer [9]. A recent article has suggested a ‘‘fast-track’’
approach with simplification of perioperative measures
including removal of the naso-gastric tube at the end of
the surgical procedure in well-selected patients [14]. On our
service, we have standardized our postoperative manage-
ment to include:
• removal of the NG tube on the day following surgery;
• maintaining an NPO status for the first 48 hours after
surgery;
• medication with proton pump inhibitors (PPI) (40 mg/day
by intravenous route) for 48 hours;
• antibiotic therapy for 48 hours, while awaiting results of
intra-operative cultures;
• abdominal drain suction;
• performance of a methylene blue dye test on the 3rd post-
operative day. If there are no signs of duodenal fistula, the
patient is then allowed to resume oral alimentation;
• an upper abdominal CT scan with GI contrast is not rou-
tinely performed. CT scan is reserved for patients with
clinical signs suggesting a postoperative duodenal fistula;
• PPI therapy is continued orally for a month and antibiotic
therapy to eradicate H. pylori is started at the time of
hospital discharge;
• patients are seen in follow-up one month after surgery
with a scheduled upper endoscopy to confirm good healing
of the duodenal ulcer and resolution of H. pylori gastritis
and to verify the absence of other associated lesions.
Disclosure of interest
The authors declare that they have no competing interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.jviscsurg.2016.02.004.
133
References
[1] Casali JJ, Franzon O, Kruel NF, Neves BD. Epidemiological anal-
ysis and use of rapid urease test in patients with perforated
peptic ulcers. Rev Col Bras Cir 2012;39:93—8.
[2] Zittel TT, Jehle EC, Becker HD. Surgical management of pep-
tic ulcer disease today — indication, technique and outcome.
Langenbecks Arch Surg 2000;385:84—96.
[3] Sivri B. Trends in peptic ulcer pharmacotherapy. Fundam Clin
Pharmacol 2004;18:23—31.
[4] Lau H. Laparoscopic repair of perforated peptic ulcer: a meta-
analysis. Surg Endosc 2004;18:1013—21.
[5] Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair
for perforated peptic ulcer disease. Cochrane Database Syst
Rev 2013;2:CD004778.
[6] Lee FY, Leung KL, Lai BS, Ng SS, Dexter S, Lau WY. Predicting
mortality and morbidity of patients operated on for perforated
peptic ulcers. Arch Surg 2001;136:90—4.
[7] Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D. Perforated pep-
tic ulcer: clinical presentation, surgical outcomes, and the
accuracy of the Boey scoring system in predicting post-
operative morbidity and mortality. World J Surg 2009;33:
80—5.
[8] Bertleff MJ, Lange JF. Laparoscopic correction of perforated
peptic ulcer: first choice? A review of literature. Surg Endosc
2010;24:1231—9.
[9] Mouly C, Chati R, Scotté M, Regimbeau JM. Prise en charge de
l’ulcère gastroduodénal perforé : revue de littérature. J Chir
Visc 2013;150:333—40.
[10] Dupont H, Bourichon A, Paugam-Burtz C, Mantz J, Desmonts
JM. Can yeast isolation in peritoneal fluid be predicted in
intensive care unit patients with peritonitis? Crit Care Med
2003;31:752—7.
[11] Turner Jr WW, Thompson Jr WM, Thal ER. Perforated gastric
ulcers. A plea for management by simple closures. Arch Surg
1988;123:960—4.
[12] Søreide K, Thorsen K, Søreide JA. Strategies to improve the
outcome of emergency surgery for perforated peptic ulcer. Br
J Surg 2014;101:e51—64.
[13] Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review
of history and treatment. Dig Surg 2010;27:161—9.
[14] Gonenc M, Dural AC, Celik F, et al. Enhanced post-operative
recovery pathways in emergency surgery: a randomised con-
trolled clinical trial. Am J Surg 2014;207:807—14.