What are the differences between the classic Graham patch repair and the modified Graham patch repair for a perforated duodenal (or gastric) ulcer?

Differences Between Classic Graham Patch and Modified Graham Patch Repair

The classic Graham patch involves simple closure of the perforation with an omental patch secured by interrupted sutures, while the modified Graham patch typically refers to primary suture closure of the perforation followed by omental patch reinforcement—the key distinction being that the modified technique includes direct suturing of the ulcer edges before applying the omental patch. 1, 2

Classic Graham Patch Technique

The original Graham patch, described by Dr. Roscoe Reid Graham in 1937, consists of:

• An omental graft held in position directly over the duodenal perforation by three interrupted sutures without primary closure of the defect itself 2
• The omentum is mobilized and plugged into the perforation site, with sutures placed through the ulcer edges and through the omental patch 2
• This technique was designed as a simple, rapid method to seal perforations and remains widely used in its original form 2

Modified Graham Patch Technique

The modified approach represents an evolution of the original technique:

• Primary suture closure of the perforation defect is performed first, followed by reinforcement with an omental patch 1, 3
• The ulcer edges are approximated with interrupted sutures, then the omental patch is placed over the repair for additional security 1, 3
• This is now considered the standard treatment approach, particularly for perforations smaller than 2 cm in hemodynamically stable patients 1, 4

Clinical Significance and Outcomes

Both techniques show comparable clinical outcomes in terms of leak rates and mortality, but the modified technique may provide additional security when tissue edges are friable: 5

• A systematic review of 6 studies found no significant difference in bile leak rates (OR 0.64; 95% CI 0.26-1.54) or mortality (OR 0.66; 95% CI 0.25-1.76) between primary closure with omental patch versus omental patch alone 5
• The modified technique with primary closure takes approximately 5.6 minutes longer than simple omental patching 5
• For perforations up to 2 cm, both approaches demonstrate low postoperative leak rates 1

Current Guideline Recommendations

Laparoscopic suture repair reinforced with an omental patch (modified technique) is the recommended approach in the emergency setting for perforated peptic ulcers: 6, 1

• The World Journal of Emergency Surgery guidelines recommend laparoscopic suture repair followed by omental patch reinforcement as a safe and effective option 6
• This modified approach is particularly valuable when ulcer edges are friable, as the omental patch reduces the risk of sutures cutting through tissue 1
• For perforations in bariatric surgery patients, the same modified technique with laparoscopic primary repair and omental patch is recommended 6, 4

Technical Considerations

The choice between classic and modified techniques should be based on perforation size, tissue quality, and hemodynamic stability:

• For small perforations (<1 cm) with healthy tissue edges, simple omental patching may suffice 1, 4
• For perforations with friable edges or those approaching 2 cm, the modified technique with primary closure plus omental reinforcement provides added security 1
• Monofilament absorbable sutures (poliglecaprone or polyglyconate) are preferred for the modified technique, as they cause less bacterial seeding and distribute tension more evenly 1

Common Pitfalls to Avoid

• Do not use overly tight sutures that can strangulate tissue and impair healing, particularly important in the omental patch 1
• Avoid attempting the modified technique in hemodynamically unstable patients—proceed directly to damage control surgery instead 6
• For large perforations (>2 cm), neither technique is optimal; consider resection or alternative approaches based on location and patient stability 6, 4
• Always obtain biopsies of gastric perforations to exclude malignancy (10-16% risk), regardless of which technique is used 4

Postoperative Management (Identical for Both Techniques)

• All patients must receive H. pylori eradication therapy with triple therapy and strict avoidance of NSAIDs and steroids postoperatively 7
• Mandatory smoking cessation is required, as smoking is a key predisposing factor for perforation 6, 7
• No routine physical activity restrictions are necessary after successful repair 7