What is the recommended surgical approach and technique for repairing a perforated peptic ulcer in a hemodynamically stable patient?

Surgical Approach and Technique for Perforated Peptic Ulcer in Hemodynamically Stable Patients

For hemodynamically stable patients with perforated peptic ulcer, perform laparoscopic simple closure with suture repair; omental patch reinforcement is only necessary for perforations >2 cm or those with friable tissue edges. 1

Timing of Surgery

Surgery must be performed as soon as possible—each hour of delay beyond hospital admission decreases survival probability by 2.4% over the first 24 hours. 1, 2

• Perforation-to-surgery interval >36 hours significantly increases postoperative mortality 1, 2
• Patients >70 years old and those with delayed presentation require particularly urgent intervention 1
• Do not delay surgery for extensive preoperative optimization 2, 3

Surgical Approach Selection

Laparoscopic Approach (Preferred for Stable Patients)

Laparoscopic repair is the recommended approach for hemodynamically stable patients, offering less postoperative pain and fewer wound infections compared to open surgery. 1

• Meta-analysis of 8 RCTs (615 patients) showed no difference in mortality, leak rates, intra-abdominal abscesses, or reoperation rates between laparoscopic and open approaches 1
• Laparoscopic approach provides significantly reduced postoperative pain in the first 24 hours and fewer wound infections 1
• Conversion to open surgery occurs in 15-27% of cases, primarily due to perforation ≥1 cm or inability to locate the perforation 1, 3

When to Use Open Surgery

Open surgery is mandatory if laparoscopic skills/equipment are unavailable or if the patient has severe cardiovascular/pulmonary comorbidity that precludes pneumoperitoneum. 1

• CO2 insufflation causes increased systemic vascular resistance, mean arterial pressure, afterload, heart rate, and PaCO2, while reducing stroke volume, venous return, and cardiac output 1
• These physiologic effects preclude laparoscopy in patients with severe cardiopulmonary disease 1

Surgical Technique

Standard Three-Port Laparoscopic Technique

Use a three-port laparoscopic approach with direct visualization of the perforation, followed by suture closure. 4

• All 42 patients in one series underwent successful three-port laparoscopic repair without conversion 4
• Operative time averages 77 minutes (range 40-120 minutes) 5

Repair Method Based on Perforation Size

For perforations <2 cm with healthy tissue edges, perform simple suture closure without omental patch—this reduces operative time without compromising outcomes. 1, 2

• Simple closure takes significantly less operative time than omentoplasty for perforations <12 mm 2
• Multiple studies show comparable leakage rates between simple closure and omental patch repair for small perforations 1, 2
• One study of 179 patients showed no difference in hospital stay, time to resume oral intake, or postoperative complications between patch and non-patch groups 6

For perforations ≥2 cm or those with friable edges, add omental patch reinforcement to reduce risk of sutures cutting through tissue. 1, 2

• Omental patch provides additional tissue support when ulcer edges are not healthy 1, 2
• Large perforations have higher leak rates (up to 12-17%) and benefit from patch reinforcement 7, 8

Sutureless Repair: Not Recommended

Avoid sutureless fibrin glue repair due to high leakage rates (16%) and reoperation rates (10%) compared to suture repair (6% leak rate, 4% reoperation rate). 1

• Prospective study of 374 patients showed conversion rates of 27% for fibrin glue repair versus 15% for suture repair 1
• Main reasons for conversion were perforations ≥1 cm and failure to locate perforation 1

Critical Intraoperative Steps

Mandatory Biopsy of Gastric Perforations

Always obtain biopsies of gastric perforations to exclude malignancy—10-16% of gastric perforations are caused by gastric carcinoma. 2, 3, 8

• For large gastric ulcers (≥2 cm) with suspicious appearance, perform resection with intraoperative frozen section examination 2, 3
• This step is mandatory regardless of perforation size or appearance 2, 3

Complete Peritoneal Lavage

Perform thorough irrigation and suction of the entire abdominal cavity to remove contaminated fluid and reduce infection risk. 5

• Laparoscopic peritoneal washout was successful in 34 of 39 patients in one series 5

Common Pitfalls to Avoid

• Do not routinely apply omental patch for small perforations (<2 cm) as it increases operative time without improving outcomes 1, 2
• Never omit biopsies of gastric perforations regardless of size or appearance—missing malignancy occurs in 10-16% of cases 2, 3, 8
• Do not delay surgery for preoperative optimization—each hour of delay decreases survival by 2.4% 1, 2
• Avoid attempting laparoscopy without adequate skills and equipment—conversion rates are high (15-27%) and open approach is safer if expertise is lacking 1

Expected Outcomes

• Postoperative leak rate: 7.1% with conservative management typically successful 4
• Deep space infection rate: 4.7% managed with ultrasound-guided drainage 4
• Mortality primarily related to high Boey Score (≥3) and ASA classification >III 4
• Mean hospital stay: 4-9 days depending on complications 5, 9