What is a Graham Patch?
A Graham patch is a surgical technique where an omental (or alternative tissue) patch is sutured over a perforated peptic ulcer to seal the defect and prevent peritoneal contamination. 1
Surgical Technique
The Graham patch repair involves the following key steps:
The omentum (greater omentum) is mobilized and placed over the perforation site, then secured with sutures that pass through the ulcer edges and incorporate the omental tissue to create a seal 2, 3
The technique is particularly valuable for perforations smaller than 2 cm in diameter, where primary closure with omental reinforcement is the standard approach 1, 4
Both open and laparoscopic approaches can be used for Graham patch repair, with the choice based on surgeon experience and patient stability 2, 5
When Graham Patch is Recommended
For perforated peptic ulcers in the emergency setting, laparoscopic suture repair reinforced with an omental patch is the recommended approach. 1
Specific indications include:
Perforated marginal ulcers or gastric/duodenal perforations less than 1 cm in hemodynamically stable patients 4
Ulcers with friable (fragile) edges where the omental patch reduces the risk of sutures cutting through the tissue 4
Perforations up to 2 cm in diameter have shown low postoperative leak rates with this technique 4
Alternative Tissue Options
When adequate omentum is unavailable, alternative tissues can be used:
The gastrocolic ligament has been successfully used as an alternative patch material in patients with insufficient viable omentum 6
The falciform ligament (falciformopexy) is another viable alternative, with perioperative mortality of 4.38%, wound infection rate of 6.66%, and reoperation rate of 1.76% 7
Jejunal serosal patches have also been reported as alternatives 6
Optimal Suture Selection
Monofilament absorbable sutures are recommended for omental patch repair as they cause less bacterial seeding and lower infection risk compared to multifilament options 4
Monofilament synthetic sutures such as poliglecaprone and polyglyconate are preferred 4
Barbed sutures can significantly reduce operative time (96.93 minutes vs 123.97 minutes) without increasing morbidity or mortality 3
Continuous non-locking suturing techniques distribute tension more evenly across the suture line 4
Clinical Context and Outcomes
The Graham patch has been used in 37% of patients with complicated ulcers in excluded gastric segments after bariatric surgery, alongside other techniques like oversewing 1
Current trends show:
Laparoscopic Graham patch repair has increased from 3.8% to 34.6% between 2005-2017, though open repair still constitutes the majority of cases 5
Multiple retrospective studies show low postoperative leak rates even for perforations up to 2 cm 4
Some studies suggest simple closure without omental patch may have comparable leakage rates while requiring less operative time, though the patch remains valuable for selected cases 4
Common Pitfalls
Avoid overly tight sutures that can strangulate tissue and impair healing, particularly important in vascular areas like the omental patch 4
Ensure adequate assessment of the jejuno-jejunostomy in bariatric patients, as gastric remnant perforation could be secondary to bowel obstruction 1
While omental patch may not be necessary for all repairs, it remains valuable for cases with friable tissue edges or larger perforations 4