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.
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.
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.
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.
The skin is prepared in the usual manner.
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; therefore, care is exercised in approaching the perforation to avoid unnecessary soiling.
The easiest method of closure consists of placing three sutures of fine silk through the submucosal layer on one side and extending through the region of the ulcer and 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. The long ends are retained (Figure 2). The closure is reinforced with omentum by separating the long ends of the three previously tied sutures and placing a small portion of omentum along the suture line. The ends of these sutures are loosely tied, anchoring the omentum over the site of the ulcer (Figure 3).
The tissue may be so indurated that the ulcer cannot be closed successfully, making it necessary to seal the perforation by anchoring omentum directly over the ulcer.
In the presence of a perforated gastric ulcer, a small biopsy of the margin of the perforation is taken because of the possibility of malignancy (Figures 4 and 5). The omentum may be anchored over the suture line (Figure 6). Closure of a gastric ulcer may be reinforced with a layer of interrupted silk serosal sutures since there is little danger of obstruction.
In the presence of perforation of an obvious carcinoma, it is usually safer to close the perforation, to be followed by resection upon recovery. If the patient's general condition is good and the perforation has lasted only a few hours, a gastric resection may be justified. Vagotomy and pyloroplasty or antrectomy for an early perforated duodenal ulcer in a good-risk patient is preferred by some surgeons.
All exudate and fluid are removed by suction. Repeated irrigation of the peritoneal cavity with saline should be considered when there is gross contamination by food particles. The wound is closed without drainage. A temporary Stamm gastrostomy (Plate 9) should be considered since prolonged obstruction of the pylorus may occur.
The patient, when conscious, is placed in Fowler's position. Constant gastric suction is continued for several days until there is reasonable assurance that the pylorus is not occluded by edema. The tube is removed when the stomach is emptying satisfactorily. The fluid balance is maintained by intravenous infusions. Antibiotics are continued. Medications that lessen gastric acid secretion may be given intravenously. After 3 to 4 days, the patient is started on a strict ulcer diet regimen. Simple closure of the perforation has not cured the patient's ulcer or the patient's tendency to form another. It must be remembered that a subphrenic or a pelvic abscess may complicate the postoperative period. Serum gastrin levels are determined and intensive medical treatment is continued.