Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer 319

Duodenum

Omental pedicle

Omentum plug inside

perforated ulcer

Stomach

FIGURE 29–5

◆ Figure 29-5 illustrates a cross-section of the ﬁ nal repair showing the omental pedicle seal-

ing the perforated ulcer.

320 Section IV • The Abdomen

Laparoscopic:

◆ Depending on the preference of the surgeon and the patient’s characteristics, a laparoscopic

closure of the perforated ulcer can be accomplished.

◆ Figure 29-6 illustrates port placement for performing the laparoscopic procedure. Trocars

are placed subcostally and one below the xiphoid process. The camera port is placed supe-

rior to the umbilicus. Upon entering the abdomen, the surgeon achieves visualization of the

perforated peptic ulcer (Figure 29-7).

Port Placement

FIGURE 29–6

Peptic ulcer

FIGURE 29–7

CHAPTER 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer 321

◆ The closure of the perforation is achieved in a similar fashion as noted for the open proce-

dure (Figure 29-8, A). The stomach is grasped at the pylorus, and the duodenum is

grasped distal to the perforation. Interrupted sutures are placed across the ulcer bed laparo-

scopically (Figure 29-8, B).

◆ A pedicle of omentum is identiﬁ ed and grasped with the trocar and positioned over the

ulcer bed (Figure 29-9).

Omentum to be used

to plug inside of

perforated ulcer

FIGURE 29–9

FIGURE 29–8

322 Section IV • The Abdomen

◆ The interrupted sutures are tied over the omental pedicle (Figure 29-10).

3. CLOSING

◆ If an open repair has been performed, the midline excision is closed in the usual fashion.

If the operation is performed laparoscopically, the trocar sites are approximated using a

subcuticular absorbable suture.

STEP 4: POSTOPERATIVE CARE

◆ Intravenous ﬂ uids and antibiotics should be continued over the postoperative period.

◆ Medical treatment for the ulcer disease should also be continued, as well as assessment of

H. pylori, which should be treated if identiﬁ ed.

◆ With return of bowel function and absence of any signs of intra-abdominal sepsis, clear

liquids can be instituted and the diet rapidly advanced as tolerated.

Omentum secured

over ulcer

FIGURE 29–10

STEP 5: PEARLS AND PITFALLS

◆ The Graham closure of a perforated peptic ulcer is usually a highly effective and efﬁ cient

way of controlling the perforation site.

◆ A well-vascularized pedicle of omentum must be selected and approximated under no

tension.

◆ If the patient has a history of chronic ulcer disease that has been unsuccessfully treated

with medical management, a more deﬁ nitive ulcer operation, such as a truncal vagotomy

and pyloroplasty, should be performed depending on the amount of contamination in

the abdominal cavity and the duration of the perforation. However, as noted previously,

the current medical regimens for ulcer treatment have greatly diminished the need for a

deﬁ nitive operation at the time of ulcer closure.

◆ The abdomen should be copiously irrigated with saline to decrease the chances of intra-

abdominal abscess forming after the procedure.

SELECTED REFERENCES

1. Mercer DW, Robinson EK: Stomach. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biologi-

cal Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008, pp 1223-1277.

2. Thompson JC: Perforation of duodenal ulcer: Treatment by simple closure or by closure plus acid-

reducing operation. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and Small

Bowel. St Louis, Mosby-Year Book, 1992, pp 113-119.

CHAPTER 29 • Open and Laparoscopic Closure of Perforated Peptic Ulcer 323

324

STEP 1: SURGICAL ANATOMY

◆ Bleeding duodenal ulcers are normally located posteriorly in the ﬁ rst portion of the duode-

num, with the bleeding due to penetration into the gastroduodenal artery (Figure 30-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Most patients with bleeding duodenal ulcers will stop bleeding and can be managed with

nonoperative medical management or endoscopic treatment, which includes injection of the

ulcer bed or actual ligation of the visible vessel. These techniques are usually highly effective;

however, surgery is required if these measures are unsuccessful and the patient continues to

bleed.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The abdomen is usually approached via an upper midline incision, which allows good

exposure and can be performed quickly.

2. DISSECTION

◆ The ﬁ rst step is to perform a Kocher maneuver to mobilize the ﬁ rst and second portions

of the duodenum, followed by a horizontal pyloroplasty, as noted by the dashed line in

Figure 30-2.

◆ Traction sutures are placed in the mid-portion of the superior and inferior limbs of the

pyloroplasty incision to afford exposure of the bleeding ulcer. Once the ulcer is identiﬁ ed,

the ongoing bleeding can be controlled using a ﬁ nger and placement of a 2-0 silk suture

(U-stitch) to control the bleeding and occlude any collateral bleeding from the transverse

pancreatic artery (Figure 30-3).

CHAPTER

Bleeding Duodenal Ulcer

B. Mark Evers

CHAPTER 30 • Bleeding Duodenal Ulcer 325

Gastroduodenal

artery

Transverse

pancreatic artery

FIGURE 30 –1

FIGURE 30 –3

FIGURE 30 –2

◆ After the U-stitch is tied, sutures are placed above and below the ulcer crater to ligate the

gastroduodenal artery (Figure 30-4).

◆ The horizontal pyloroplasty is then closed in a vertical fashion (Heineke-Mikulicz pyloro-

plasty), and a truncal vagotomy is performed (Figure 30-5).

FIGURE 30 –4

FIGURE 30 –5

Section IV • The Abdomen326

3. CLOSING

◆ The midline incision is closed in the usual fashion.

STEP 4: POSTOPERATIVE CARE

◆ Intravenous ﬂ uids are continued postoperatively.

◆ The patient is usually monitored in the intensive care unit for possible signs of rebleeding

and to ensure adequate hemodynamics.

◆ Once bowel function resumes, the nasogastric tube can be discontinued and clear liquids

initiated with rapid advancement of the diet as tolerated.

STEP 5: PEARLS AND PITFALLS

◆ In addition to the sutures placed above and below the ulcer crater, it is important to place

the U-stitch to prevent rebleeding from a collateral anastomosis from the transverse pancre-

atic artery. The application of this technique has diminished the incidence of post–suture

ligation rebleeding.

SELECTED REFERENCES

1. Mercer DW, Robinson EK: Stomach. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biologi-

cal Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008, pp 1223-1277.

2. Thompson JC: Pyloroplasty for bleeding duodenal ulcer using the U-stitch. In Thompson JC (ed): Atlas of

Surgery of the Stomach, Duodenum and Small Bowel. St Louis, Mosby-Year Book, 1992, pp 109-111.

CHAPTER 30 • Bleeding Duodenal Ulcer 327

328

STEP 1: SURGICAL ANATOMY

◆ The vagus nerves are not always easily identiﬁ ed. Sometimes their location can be more

quickly discovered by palpation. The left vagus nerve is usually located on the anterior

surface of the esophagus, a little to the left of the midline, whereas the right vagus nerve

is usually located a little to the right of the midline, posteriorly. The left vagus nerve is inti-

mately associated with the anterior surface of the esophagus, whereas the right vagus nerve

is located in the tissue adjacent to the posterior esophagus (Figure 31-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Truncal vagotomy provides a safe and simple means for reducing acid secretion by the

stomach. Because the vagus provides motor ﬁ bers to the circular muscle of the antrum, a

truncal vagotomy must be accompanied by a procedure to facilitate gastric drainage, such

as a pyloroplasty or gastroenterostomy. The advantages of truncal vagotomy are that it is

safe and many of the serious late postgastrectomy sequelae can be avoided.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ For an open truncal vagotomy procedure, a standard upper midline incision is performed.

◆ Retraction is obtained with self-retaining retractors, which allow excellent exposure of the

distal esophagus and upper stomach.

2. DISSECTION

◆ The left lobe of the liver is retracted upward and toward the midline, so as to clearly expose

the gastroesophageal junction. The peritoneal reﬂ ection at the diaphragm is incised to

expose the esophagus as shown by the dashed line (Figures 31-2 and 31-3).

CHAPTER

Truncal Vagotomy

B. Mark Evers