What is Graham patch repair?

Graham Patch Repair: Surgical Technique for Perforated Peptic Ulcers

Graham patch repair is a surgical technique used to treat perforated peptic ulcers by closing the perforation with sutures and reinforcing it with a piece of omentum, though evidence suggests simple closure without an omental patch may be equally effective for perforations smaller than 2 cm. 1

Definition and Technique

Graham patch repair (also known as omentopexy) involves:

1. Identification of the perforation site (typically on the anterior surface of the duodenum)
2. Closure of the perforation with sutures
3. Placement of a piece of omentum over the repair site
4. Securing the omental patch to provide reinforcement

Clinical Applications

Perforation Size Considerations

• Small perforations (<2 cm):

  • Primary repair with simple suture closure is recommended
  • Adding an omental patch (Graham patch) is optional and does not clearly improve outcomes 1
  • Multiple studies show comparable leakage rates between simple closure and omentopexy 1

• Large perforations (≥2 cm):

  • Requires a tailored approach based on location
  • For large gastric ulcers: Consider resection (especially if malignancy is suspected)
  • For large duodenal ulcers: Consider resection or repair with/without pyloric exclusion 1

Surgical Approach

• Can be performed via open surgery or laparoscopically
• Laparoscopic approach offers benefits including:
  • Less postoperative pain
  • Lower wound infection rates
  • Earlier removal of nasogastric tubes
  • Earlier resumption of diet
  • Shorter hospital stays 2

Modifications and Alternatives

Several modifications of the Graham patch technique exist:

1. Modified Cellan-Jones repair: A variation of the Graham patch technique used in laparoscopic approaches 2

2. Modified Graham patch with barbed suture: Combines barbed suture with omental patch, potentially reducing surgical time without increasing complications 3

3. Alternative tissue patches: When viable omentum is unavailable, the gastrocolic ligament can be used as an alternative for the patch repair 4

Efficacy and Outcomes

• Success rate of laparoscopic repair: approximately 84.7% 5
• Postoperative complications to monitor:
  • Leakage (occurs in approximately 1-2% of cases) 1
  • Wound infection (lower with laparoscopic approach) 5

Clinical Considerations

• The addition of an omental patch:

  • Increases operative time
  • Requires more advanced laparoscopic skills
  • Shows similar results to simple closure for small perforations 1
  • May be beneficial for ulcers with friable edges to reduce risk of sutures cutting through tissue 1

• For optimal outcomes, consider:

  • Patient's overall condition
  • Size and location of perforation
  • Surgeon's experience with laparoscopic techniques
  • Presence of viable omentum for patch creation

Important Caveats

• The routine application of omental patch is not clearly supported by evidence for perforations <2 cm 1
• Laparoscopic repair has a higher reoperation rate compared to open repair, despite other benefits 5
• Large gastric ulcers should raise suspicion for malignancy (10-16% of gastric perforations are caused by gastric carcinoma) 1
• Following repair, patients should receive appropriate treatment for the underlying cause, including Helicobacter pylori eradication when indicated 6