The perforated ulcers were treated by open gastrectomy or simple suture until 1937 then Graham introduced the method using a free omental graft, which is called the “Graham patch procedure” [1]. This procedure has long been a golden standard of surgical treatment for perforated peptic ulcers. The idea of laparoscopic treatment had arisen in the 1990s, and the comparison of superiority between laparoscopy and open surgery has long been discussed [2].

Recently reported meta-analysis had shown the significance of laparoscopic repair over the open repair for postoperative pain in the first 24 h and postoperative wound infection, and equivalence of multiple clinical outcomes [3]. In addition, explorative laparoscopy will be useful to gain more information about the perforation site and decide to move on to laparoscopic repair or switch to open repair. Therefore, in a facility where there is a surgeon that is well trained in the laparoscopic procedure, laparoscopic repair is a better choice for the patient.

Indications for Operation

  • Perforated ulcer with no evidence of spontaneous seal.

Indications for Nonoperative Management

  • Clinically stable, without signs and symptoms of sepsis, and with good radiologic evidence that the perforation has sealed.

  • Low risk (Boey score* of 0,1).

*Boey score: shock on admission, ASA grade III–IV, symptom duration(>24 h) [4]. The maximum score is 3, which is indicated high surgical risk.

Contraindications for Laparoscopic Repair

  • High-risk patient (Boey score of 3).

  • Clinical evidence of concomitant bleeding ulcer.

  • Previous abdominal surgery (relative).

Preoperative Assessment

  • Fluid resuscitation.

  • Preoperative antibiotics (cover gram-negatives, anaerobes, mouth flora, and fungi).

  • Intravenous PPI.

  • Kept NPO and insertion of nasogastric (NG) tube.

  • Adequate analgesics.

  • Prophylactic anticoagulation.

OT Setup and Patient’s Position

  • Patient is placed in the modified lithotomy position (Lloyd-Davies).

  • Surgeon stands between the legs of the patient.

  • Assistant stands on the left side of the patient.

  • Monitor is positioned above the patient’s right shoulder (Fig. 1).

Fig. 1
A photograph of O T setup and patent position for a surgical technique.

OT setup and patient position

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Instrumentations Required

  • 10 mm 30° laparoscope

  • Scissors.

  • Grasper.

  • Needle holder.

  • Suction device.

  • 3–0 absorbable suture needle

  • 10 mm periumbilical trocar

  • Two 5 mm trocars are positioned on either side along the midclavicular line at the level of the umbilicus.

  • One 5 mm trocar at the subxiphoid region is placed for retraction of liver or gallbladder.

Surgical Technique

Identification of the Site of Perforation

  • Insert camera and the rest of the trocars in place. Pneumoperitoneum is established and maintained 10–12 mm Hg. Change the patient’s position to reverse Trendelenburg position and retract the liver to the cranial side to expose the stomach and duodenum.

  • Gently investigate the organs and look for the perforation site. Bacteriologic and fungal cultures are taken. A biopsy is recommended to perform for gastric ulcer perforation since malignancy can be occasionally seen.

  • Even in the case of perforated gastric cancer, a two-stage procedure should be performed in most cases, consisting of suture closure of the perforation followed by a second-stage gastrectomy [5].

Peritoneal Washing

  • Start with exploring the entire abdomen and removing purulent collections and gastric/bowel contents using suction to gain proper field of view. Change the patient’s position to Trendelenburg position when exploring the pelvic cavity. If the patient has suffered more than 24 h after the onset, some fibrin formation may be seen throughout the entire abdomen.

  • Be sure to conduct lavage enough so that the omentum is clean without any pleural collections, gastric/bowel contents, or fibrin before moving on to coverage of the perforation with omentum.

Closure of the Perforation

Method of closure depends on the size of the perforation;

<1 cm: closure by interrupted sutures covered with a pedicled omentum on top of the repair (Cellan-Jones repair [6]).

Applicate standard stitches with 3–0 absorbable sutures to close the perforation. When pulling the omentum to cover the suture line, be sure to avoid any tension. Do 3–4 additional stitches to fix the omentum to the suture line. The last procedure may be omitted; some studies which compared the sutureless onlay omental patch method with sutured omental patch method showed that either group never had postoperative leaks, and the former method had significantly shorter operative time and length of stay [7].

Perforated duodenal ulcer repair is done by placing sutures through the full thickness of the bowel wall with 3–0 absorbable suture (Figs. 2 and 3).

Fig. 2
Pictures of the perforated ulcer with fully sutured walls. The digestive tract's layers can be penetrated by the ulcer, creating a hole.

Perforated ulcer with full-thickness wall suturing

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Fig. 3
With the needle held with its concavity curved downward, a suture is tied using the intracorporeal method.

The sutures are tied using the intracorporeal technique

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1–2 cm: plugging the perforation with a free omental plug (Graham patch [1]).

If the perforation is 1 ~ 2 cm, the standard stitch may give too much tension to the suture line. Therefore, the operator should skip the standard suture process and directly move on to covering and fixing the omentum to the perforation. If the perforation is too big or damaged too much to suture, stuffing the omentum into the perforation would be enough (Fig. 4).

Fig. 4
An image of a peritoneum fold connecting the stomach to other abdominal organs is restored with a thin, sickle-shaped, fibrous structure connecting the anterior part of the liver to the ventral wall of the abdomen.

Omentum is brought up to the site of perforation to ensure adequate length without tension. The omentum was fixed with the falciform ligament to prevent dislodging

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>2 cm: If the perforation size is more than 2 cm, it may be difficult to proceed graham patch closure. The operator should consider converting to laparotomy.

After Closure

After the perforation is properly covered, irrigate the peritoneal cavity with at least 5 l of warm saline to wash off the impurities. To confirm the closure is watertight, instillation of intragastric air or methylene blue via the NG tube is useful. Drains are optional; however, there is no evidence to support their routine use. Remove trocars one after another and be sure that there is no active hemorrhage of trocar sites. Close the skin with sutures.

Complications and Management

  • Leakage: repeat laparoscopy and rerepair laparoscopically or convert to an open procedure.

  • Intra-abdominal abscess: percutaneous drainage.

  • Intestinal obstruction.

Postoperative Care

  • NG tube is removed after 24 h when the residual gastric aspirates are minimal.

  • Oral intake is commenced once there is a return of bowel function.

  • PPI.

  • Antibiotics.

  • Upper endoscopy is performed 6–8 weeks later to check H.pylori status and to assess for healing in gastric ulcer perforation.