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INDICATIONS

The laparoscopic approach is indicated in patients with a suspected or confirmed perforation of a duodenal ulcer. It is a suitable alternative to the standard open Graham patch repair, except in cases of prior upper abdominal surgery. Simple closure of the perforation is indicated for patients with ongoing instability, delayed presentation, or prohibitive medical comorbidities.

Rarely is “definitive” ulcer surgery indicated, but it may be considered for those who are Helicobacter pylori negative, do not use nonsteroidal anti-inflammatory agents (NSAIDs), and have well-documented recurrent peptic ulcer disease. In the absence of gastric outlet obstruction, the operation of choice is highly selective vagotomy. In the presence of gastric outlet obstruction, antrectomy and reconstruction or gastrojejunostomy may be considered.

PREOPERATIVE PREPARATION

These patients classically present with a history of previously diagnosed peptic ulcers or may report long-term use of NSAIDs. A plain film radiograph may show free air. The diagnosis may be confirmed with an upper gastrointestinal radiograph with water-soluble contrast, not barium. However, a prolonged workup to confirm a diagnosis may be counterproductive, as early surgical intervention is usually warranted.

The patient should have good intravenous access and be adequately resuscitated. Appropriate antibiotic coverage should be given preoperatively.

ANESTHESIA

General anesthesia with endotracheal intubation is necessary for this operation. Complete neuromuscular blockade is required. Given the incidence of concurrent gastritis in these patients, the use of ketorolac for pain control should be avoided in the postoperative period.

POSITION

The patient is positioned supine in modified lithotomy with arms tucked at the sides. The surgeon stands between the legs, and the assistant stands to the left side of the patient. The operative monitors are placed above the patient’s head (Figure 1).

OPERATIVE PREPARATION

A Foley catheter and orogastric tube are placed after the induction of anesthesia. The abdomen of the patient from the nipple lines to the pubis is shaved with clippers after induction of anesthesia, and the abdomen is sterilely prepped.

DETAILS OF PROCEDURE

Trocar Position

Because the abdominal wall is thinnest in the region of the umbilicus, this operation commences with insufflation of the abdomen using the Veress needle technique placed through the umbilicus. Alternatively, initial access may be achieved using the Hasson technique at the umbilicus.

The procedure may be performed with a three-trocar technique (Figure 2). A 10-mm cannula for the endoscope is placed at the umbilicus. Depending on the size of the patient and distance to the stomach, the camera port may need to be placed more cephalad along the midline. A 5-mm port is placed in the right subcostal region ...

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