Plate 11

### Indications

Perforation of an ulcer of the stomach or duodenum is a surgical emergency; however, before performing the operation, sufficient time should be allowed for the patient to recover from the initial shock (rarely severe or prolonged) and for the restoration of the fluid balance. The choice for closure of the perforation versus a definitive ulcer procedure depends upon the overall assessment of risk factors by the surgeon.

### Preoperative Preparation

A narcotic is used to control pain only after the diagnosis is established. The intravenous administration of saline, glucose, and colloids may be necessary, depending upon the patient's general condition and the length of time that has elapsed since perforation. The parenteral administration of antibiotics and the institution of constant gastric suction are routine.

### Anesthesia

General endotracheal anesthesia combined with muscle relaxants is preferred. In the poor-risk patient or patients with severe respiratory infection, local infiltration anesthesia is substituted.

### Position

The patient is placed in a comfortable supine position with the feet slightly lower than the head to assist in bringing the field below the costal margin and to keep gastric leakage away from the subphrenic area.

### Operative Preparation

The skin is prepared in the usual manner.

### Incision and Exposure

Since the majority of perforations occur in the anterior superior surface of the first portion of the duodenum, a small, high, right rectus midline or right paramedian incision is made. A culture of the peritoneal fluid is taken, and as much exudate as possible is removed by suction. The liver is held upward with retractors, exposing the most frequent sites of perforation. The site may be walled off with omentum if the perforation has been present several hours; ...

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