Surgical Management of Pneumoperitoneum Due to Perforated Gastric Ulcer
Immediate surgical intervention is mandatory for patients with pneumoperitoneum due to perforated gastric ulcer, as every hour of delay from admission to surgery decreases survival probability by 2.4%. 1, 2
Initial Assessment and Stabilization
- Hemodynamic stability assessment is crucial as it determines the surgical approach 1
- Patients presenting with rigid abdominal pain and free air on imaging require immediate surgical intervention 2
Surgical Approach Based on Patient Status
For Hemodynamically Stable Patients:
- Laparoscopic approach is preferred for stable patients with perforations less than 1 cm 1
- If appropriate laparoscopic skills or equipment are unavailable, especially in unstable patients, open approach is recommended 3
For Hemodynamically Unstable Patients:
- Open approach should be considered for patients with hemodynamic instability or severe sepsis 1, 2
- Damage control surgery and open abdomen approach should be considered in critically ill patients 1
Management Based on Perforation Size
Small Perforations (<2 cm):
- Simple closure with or without an omental patch is safe and effective 3
- Primary suture with omental patch reinforcement is the standard treatment, though studies show similar outcomes with simple closure alone 3, 1
- Multiple studies highlight low postoperative leak rates with the omental patch technique, even in perforations up to 2 cm in diameter 3
Large Perforations (≥2 cm):
- A tailored approach based on ulcer location is necessary 3, 1
- For large gastric ulcers with suspicion of malignancy, resection with intraoperative frozen section examination is recommended 3, 1
- Gastric resection and reconstruction should be the surgical choice for perforated gastric ulcers larger than 2 cm 3
Special Considerations
- Biopsies of the perforated ulceration must be taken to exclude malignancy, as 10-16% of gastric perforations may be caused by gastric carcinoma 3, 1
- The proximity of duodenal perforations to the common bile duct and ampulla of Vater must be thoroughly investigated 3, 2
- Intraoperative cholangiography may be necessary to verify common bile duct anatomy in complex cases 3, 2
Postoperative Management
- Postoperative leak occurs in approximately 12-17% of cases and requires careful monitoring 4
- Serial measurements of amylase and lipase every 6 hours are recommended to track clinical course, particularly with duodenal perforations 5
- Persistently elevated amylase levels after repair may indicate inadequate closure or development of a fistula 5
Common Pitfalls to Avoid
- Failure to obtain biopsies during repair, potentially missing malignancy 1
- Attempting complex resections in hemodynamically unstable patients 1, 2
- Underestimating the severity of peritonitis, which may require a more aggressive surgical approach 1, 2
- Delayed recognition of tension pneumoperitoneum, which requires immediate needle decompression if suspected 6