Perforated Peptic ulcer

Perforated peptic ulcer
1.Position the patient supine.
2.Make an upper midline incision
3.Conduct a laparotomy to determine the cause for the patient’s illness by examining the colon, SB, GB.
4.Follow the lesser curve of the stomach to find the site of perforation. If no disease is found examine the posterior surface of stomach and lesser sac.
5.Once perforation identified and any gross contaminating fluid aspirated, place three plication sutures in the long axis of the duodenum and hold them with an artery forcep.
6.Isolate a viable segment of omentum and secure it to the defect using the previously placed sutures. (Graham patch 1937) Alternatively can use piece of falciform
7.Lavage and mass abdominal closure (don’t usually drain)

Options for a difficult duodenal stump
1.Nissen Cooper technique whereby the anterior and posterior walls of the duodenum are sutured to the distal lip of the ulcer. A further layer of sutures is placed in the pliable anterior wall of the duodenum, suturing it to the proximal lip of the ulcer in an inverting manner.
2.Catheter duodenostomy (14F whistle-tip or Foley catheter brought out through the defect in the stump) to protect the integrity of a difficult stump closure.
3.Closure with a TA60 (4.8mm staples) stapler generally requires at least 1.5cm of pliable duodenum, in which case you should be able to do a Bilroth I.

Options for a bleeding duodenal or pyloric ulcer
1.Make a longitudinal gastroduodenotomy directly over the pyloric ring and oversew the bleeding point as well as in four quadrants around this point.
2.Repair with either a Heinecke-Mikulicz pyloroplasty or a Finney pyloroplasty.

Giant ulcer
10Fr Foley retrograde into 2nd part duodenum with distal feeding jejunostomy

Laparoscopic repair
Stapler or suture repair