What is the initial approach for a patient presenting with a perforated gastric ulcer, specifically regarding gastrotrrhapy (surgical repair of the stomach)?

Gastrorrhaphy for Perforated Gastric Ulcer

For hemodynamically stable patients with perforated gastric ulcers, perform laparoscopic primary suture repair with omental patch reinforcement—this is the standard of care for perforations less than 1 cm. 1, 2

Immediate Assessment and Surgical Timing

Hemodynamic status determines your entire surgical approach. Unstable patients require immediate surgical exploration without delay 1, 2. Do not waste time with extensive preoperative workup in unstable patients—get them to the operating room.

Surgical Approach Based on Patient Stability

Hemodynamically Stable Patients

• Laparoscopic approach is preferred for stable patients with perforations <1 cm 1, 2
• Primary suture with omental patch (Graham patch) is the standard technique 1, 2, 3
  • This combination is safe, feasible, and associated with decreased operative time, blood loss, and length of stay 1
  • Simple closure without omental patch may be considered in selected cases, though omental reinforcement is particularly useful for large perforations with friable tissue 3, 4
• Running suture technique (Lahodny suture) is a valid alternative that avoids intra-corporal knotting and is simple to perform 5
• Minimally invasive surgery has superior outcomes compared to open techniques 3

Hemodynamically Unstable Patients

• Consider damage control surgery with open abdomen approach 1, 2
• Focus on controlling contamination and stabilizing the patient—avoid complex definitive procedures 2
• Open abdomen is appropriate for severe peritonitis with septic shock, extensive visceral edema, or concerns for abdominal compartment syndrome 1

Critical Intraoperative Steps

Mandatory Biopsy

Always obtain biopsies of the perforated ulceration to exclude malignancy—this is a strong recommendation that cannot be skipped 1, 2. Between 10-16% of gastric perforations may be caused by gastric carcinoma 2, and missing this diagnosis has devastating consequences 4.

Perforation Size-Based Management

Small perforations (<1 cm):

• Primary suture with omental patch is standard 1, 2

Large perforations (≥2 cm):

• Tailored approach based on ulcer location 2, 6
• For large gastric ulcers with suspicion of malignancy, consider resection with intraoperative frozen section 2, 6
• Distal gastrectomy is indicated for large perforations near the pylorus or gastric corpus where simple repair may be inadequate 6

Special Considerations for Post-Bariatric Surgery Patients

If the patient has had previous bariatric surgery (gastric bypass), additional exploration is mandatory 1:

• Assess for gastro-gastric fistula in the presence of marginal perforated ulcer 1
• Explore the jejuno-jejunostomy for stenosis if diffuse peritonitis is present 1
• Examine the gastric remnant and excluded duodenum 1
• Laparoscopic primary repair with omental patch remains the recommended approach for stable patients 1, 7

Common Pitfalls to Avoid

• Failure to obtain biopsies—you will miss malignancy in approximately 9% of cases 4
• Attempting complex resections in unstable patients—this significantly increases mortality 2, 6
• Overlooking associated pathology in bariatric surgery patients—gastro-gastric fistula or jejuno-jejunostomy stenosis can be the underlying cause 1
• Underestimating leak rates—expect 12-17% of repairs to leak postoperatively, requiring vigilant follow-up 3

Postoperative Management

• Continue proton pump inhibitor therapy 6
• Test for Helicobacter pylori and treat if positive 6, 8
• Mandatory follow-up endoscopy with repeat biopsy to avoid missing underlying malignancy 4
• Counsel patients to avoid NSAIDs, smoking, and other ulcerogenic factors 2

Expected Outcomes

Median hospital stay is 9-10 days 5, 4. Overall morbidity remains high at approximately 50-54%, with mortality around 15-30% despite modern techniques 3, 4. Registrars can safely perform these procedures with appropriate supervision without increased morbidity or mortality 4.