What are the different types of omental patch repair?

Types of Omental Patch Repair for Perforated Peptic Ulcer

The primary types of omental patch repair are: (1) Graham patch omentopexy (standard multi-stitch technique), (2) single-stitch omental patch, and (3) combined omental plug-and-patch technique, with the choice depending on perforation size and tissue quality. 1, 2, 3

Standard Graham Patch Omentopexy

This is the traditional "gold standard" technique that has been used for decades 1:

• Multiple sutures are placed through the perforation edges and then tied over a pedicled omental flap to seal the defect 1, 4
• The omentum is mobilized and brought up to cover the perforation site, with sutures anchoring it in place 4
• This technique requires advanced laparoscopic suturing skills and takes longer operative time compared to simpler methods 1
• Best suited for perforations with friable edges where tissue quality is poor and sutures may cut through, as the omental patch provides additional reinforcement 1, 5

Single-Stitch Omental Patch Technique

A simplified modification that reduces operative complexity 2, 6:

• One suture is passed through the perforation without knotting, then tied over the omentum to simultaneously close the defect and secure the omental patch 2
• Mean operative time is approximately 50-64 minutes, significantly shorter than multi-stitch techniques 2, 6
• This technique has demonstrated acceptable morbidity rates and low conversion rates (approximately 6-15%) 2, 6
• Conversion is typically required for perforations >10 mm or when the perforation site cannot be adequately localized 2, 6
• Patients require minimal postoperative analgesia (average 0.9-1 dose per patient) and return to daily activities within 10 days 2, 6

Combined Omental Plug-and-Patch Technique

Reserved for giant perforations (>2 cm), particularly prepyloric perforations 3:

• An omental plug is first inserted into the perforation to fill the defect, then an omental patch is placed over the plug for additional security 3
• This technique addresses the unacceptably high leak rates (up to 12%) associated with standard patch repair of large ulcers 7, 3
• Case series demonstrate zero postoperative leaks and zero mortality when this combined technique is used for giant perforations 3
• Mean hospital stay is approximately 12 days 3

Primary Closure Without Omental Patch

While not technically an "omental patch" repair, this alternative warrants mention 1, 8:

• Simple suture closure without omental reinforcement has comparable leak rates and mortality to Graham patch omentopexy for small perforations (<2 cm) 1, 8
• Meta-analysis shows no difference in bile leak (OR 0.64), mortality (OR 0.66), or wound infection (OR 0.65) between primary closure and omental patch 8
• Operation time is 5.6 minutes shorter with primary closure 8
• Multiple retrospective studies confirm that adding an omental patch does not provide additional benefit for small perforations but significantly increases operative time 1

Algorithm for Selecting Repair Type

For perforations <1 cm in stable patients:

• Consider single-stitch omental patch or simple closure without patch 1, 2, 6
• Both have comparable outcomes; choose based on surgeon experience and tissue quality 1, 8

For perforations 1-2 cm with good tissue quality:

• Simple closure without patch is adequate and faster 1, 8
• Add omental patch only if edges are friable or tissue quality is questionable 1, 5

For perforations >2 cm (giant ulcers):

• Use combined omental plug-and-patch technique if attempting repair 7, 3
• However, resection is preferred for large gastric ulcers due to 10-16% malignancy risk 7
• For giant duodenal ulcers in unstable patients, consider damage control surgery rather than definitive repair 7

Common Pitfalls to Avoid

• Do not routinely apply omental patch for all small perforations (<2 cm), as it increases operative time without improving outcomes 1, 5
• Avoid attempting standard patch repair for giant perforations (>2 cm) without using the plug-and-patch technique or considering resection, as leak rates reach 12% 7, 3
• Never omit biopsy of gastric perforations regardless of repair technique chosen, as 10-16% harbor malignancy 7
• Do not attempt complex repairs in hemodynamically unstable patients; prioritize damage control surgery 7
• Avoid overly tight sutures that can strangulate tissue and impair healing, particularly when securing the omental patch 5