What are the steps for laparoscopic repair of a perforated gastric ulcer?

From the Guidelines

Laparoscopic repair of a perforated gastric ulcer is the recommended approach, involving simple or double-layer suture with or without an omental patch, as it is a safe and effective procedure for small perforations 1. The steps for laparoscopic repair of a perforated gastric ulcer include:

• Establishing pneumoperitoneum using a Veress needle or open Hasson technique
• Placing three to four ports for camera and instrument access
• Exploring the abdomen to confirm the diagnosis and locate the perforation
• Performing peritoneal lavage to remove gastric contents and purulent material
• Closing the perforation using simple interrupted non-absorbable sutures or a running suture, often reinforced with an omental patch
• Performing a leak test to confirm the integrity of the repair
• Placing drains near the repair site if necessary Key considerations include:
• The use of antibiotic therapy for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients 1
• The potential need for conversion to open surgery in cases with extensive peritonitis, large perforations, or technical difficulties
• The importance of postoperative care, including nasogastric decompression, intravenous antibiotics, proton pump inhibitors, and H. pylori eradication therapy if positive In cases with large perforations or suspicion of malignancy, a tailored approach may be necessary, including resection with contextual operative frozen pathologic examination or duodenostomy 1.

From the Research

Laparoscopic Repair of Perforated Gastric Ulcer

The steps for laparoscopic repair of a perforated gastric ulcer involve several key considerations:

• Diagnosis: Confirming the presence of a perforated gastric ulcer, often through imaging studies or endoscopy 2.
• Preparation: Ensuring the patient is properly prepared for laparoscopic surgery, including anesthesia and positioning.
• Laparoscopic approach: Using a laparoscope to visualize the perforation and surrounding tissue 2, 3.
• Omental patch repair: A common technique used to repair the perforation, where a patch of omentum is used to cover the defect 2.
• Simple closure: In some cases, the perforation may be closed directly with sutures 2.
• Distal gastrectomy: For larger perforations or those associated with gastric cancer, a distal gastrectomy may be necessary 2.

Anatomy Involved

The anatomy involved in laparoscopic repair of a perforated gastric ulcer includes:

• Stomach: The site of the perforation, which can be located in various parts of the stomach.
• Omentum: A layer of tissue that can be used to cover the perforation and promote healing.
• Duodenum: The first part of the small intestine, which can be involved in the perforation or affected by the repair.
• Surrounding tissues: Other tissues in the abdominal cavity, such as the liver, spleen, and intestines, which must be carefully avoided during the repair.

Considerations and Complications

Considerations and potential complications of laparoscopic repair of a perforated gastric ulcer include:

• Infection: The risk of infection is high in cases of perforated gastric ulcers, and antibiotic therapy may be necessary 4, 5.
• Bleeding: Bleeding can occur during or after the repair, and may require additional intervention.
• Recurrence: The risk of recurrence is higher in cases where the underlying cause of the perforation is not addressed, such as Helicobacter pylori infection 4, 5.
• Malignancy: In some cases, a perforated gastric ulcer may be associated with gastric cancer, and further evaluation and treatment may be necessary 2.