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; therefore, care is exercised in approaching the perforation to avoid unnecessary soiling.

Details of Procedure

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.

Closure

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.

Postoperative Care

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.

Indications

The most common origins of a subphrenic abscess are perforation of a peptic ulcer, perforation of the appendix, or acute infection of the gallbladder. It is to be suspected in an unsatisfactory recovery from any of these conditions. Intensive antibiotic therapy may mask the systemic reaction to the infection. Chest radiographs may show a pleural effusion and ultrasound or computed tomogrphic (CT) scans should be diagnostic. Additionally, the CT scan may guide a fine-needle aspiration for culture or the placement of a catheter for drainage if the pus is thin and the cavity is unilocular.

Preoperative Preparation

The clinical data combined with radiologic studies usually indicate the location of the abscess. The location and extent of the abscess often can be defined by CT, which may also be used to guide needle aspiration or catheter drainage. Subphrenic abscesses occur much more frequently on the right side. Antibiotics, blood transfusions, and intravenous fluids are usually necessary because of the prolonged sepsis.

Anesthesia

Local anesthesia by direct infiltration of the site of the incision is preferable for the poor-risk patient. Spinal or inhalation anesthesia also may be used, depending upon the patient's general condition.

Position

For an anterior abscess, the patient is placed supine with the head of the table elevated. For a posterior abscess, the patient is placed on the side with the arm on the affected side pulled forward.

Operative Preparation

The skin is prepared in the usual manner.

Incision and Exposure

The incision is placed one fingerbreadth below the costal margin and extended from the mid rectus region laterally (Figure 7). The free peritoneal cavity is not opened.

Details of Procedure

The surgeon inserts the index finger upward between the peritoneum and diaphragm until the abscess cavity is encountered; extraperitoneal drainage is thus established (Figure 8).

Incision and Exposure

It is desirable to drain the subphrenic abscess by the extraperitoneal route without rib resection whenever possible. On occasion, it may be desirable to approach the abscess through the bed of the twelfth rib (Figure 9, Incision A). The entire twelfth rib is resected. The erector spinae are retracted toward the midline, and a deep transverse incision is made at right angles to the vertebrae across the periosteal bed of the resected rib, opposite the transverse process of the first lumbar vertebra (Figure 9, Incision B).

Details of Procedure

The location of the abscess cavity is approached by the index finger of the surgeon, who separates the peritoneum from the undersurface of the diaphragm, thus ensuring dependent drainage without contamination of the peritoneal cavities (Figure 10). Once pus has been obtained, the abscess cavity can be entered and thoroughly evacuated, and rubber tissue drains or mushroom catheters can be inserted. Several cultures are taken routinely, and the sensitivity of the offending organism is determined. Some organisms, such as Staphylococcus, require isolating the patient to prevent spread of the organism to others.

If the abscess cavity is difficult to palpate, aspiration exploration with a 20-gauge needle on a 10-mL syringe is usually successful. Do not aspirate the cavity empty, as it will become even more difficult to palpate and find the correct pathway. Finally, if the abscess cavity has not been adequately drained with a small catheter placed under CT or ultrasound guidance, that catheter should be left in place to guide the surgeon.

Closure

Drains are inserted into the abscess cavity in numbers indicated by the size of the abscess. There is no further closure.

Postoperative Care

The abscess cavity is carefully irrigated with normal saline each day, and the capacity of the cavity measured from time to time. The external opening is maintained, and the drains or tubes are removed sequentially as the cavity is obliterated. Vigorous pulmonary and nutritional support is given, and antibiotics are continued until sepsis is over.

If the chest is entered, closure of the opening with placement of a temporary chest tube is usually necessary.