Chapter 22: Closure of Perforated Duodenal Ulcer

A. OPEN CLOSURE

INDICATIONS

Perforation of an ulcer of the stomach or duodenum is a surgical emergency, but before performing the operation, sufficient time should be allowed for the patient to recover from the initial shock (rarely severe or prolonged) and for restoration of the fluid balance. The choice for closure of the perforation versus a definitive ulcer procedure depends on the overall assessment of risk factors by the surgeon. Laparoscopic exploration with or without definitive repair is often preferred, especially in the setting of anterior perforation of the duodenum, with a plan for simple closure.

PREOPERATIVE PREPARATION

The patient may have a history of previous peptic ulcer and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). An upright plain film may show free air. If the diagnosis is in question, an upper gastrointestinal series with water-soluble contrast material may be helpful. Time is of the essence in treatment, and prolonged workups should be avoided. The intravenous administration of an appropriate type and volume of fluid is necessary depending on the patient’s general condition and the length of time that has elapsed since perforation. Parenteral administration of antibiotics and the institution of constant nasogastric suction are routine.

ANESTHESIA

General endotracheal anesthesia combined with muscle relaxants is preferred.

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

A Foley catheter and orogastric or nasogastric tube are placed after induction of anesthesia. The skin is prepared in the usual manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

Because the majority of perforations occur in the anterosuperior surface of the first portion of the duodenum, a small, high midline 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 for several hours; therefore, care is exercised in approaching the perforation to avoid unnecessary soiling.

DETAILS OF THE PROCEDURE

The easiest method of closure consists of placing three sutures of fine silk through the submucosal layer on one side with extension through the region of the ulcer and then out a corresponding distance on the other side of the ulcer (FIGURE 1). Starting at the top of the ulcer, the sutures are tied very gently to prevent laceration of the friable tissues. ...