Laparoscopic Repair of Perforated Peptic Ulcer
Save for perforated appendicitis, perforated peptic ulcer (PPU) is the most common intra-abdominal hollow viscus perforation that requires surgical intervention. The estimated annual incidence is approximately 5–10/100,000. Perforation occurs in 2–10 % of
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Jonathan B. Yuval and Amir Szold
11.1 Introduction Save for perforated appendicitis, perforated peptic ulcer (PPU) is the most common intra-abdominal hollow viscus perforation that requires surgical intervention [1]. The estimated annual incidence is approximately 5–10/100,000 [2, 3]. Perforation occurs in 2–10 % of patients with peptic ulcer disease and is the leading cause of death due to PUD [3]. Ulcer perforation is most commonly found in the anterior portion of the first part of the duodenum and usually is of a diameter smaller than 5 mm [3].
11.2 Clinical Presentation and Diagnosis Patients with perforated peptic ulcers most commonly present with sudden severe epigastric pain that may radiate to the shoulder and is often associated with nausea and vomiting [3]. Presentation also typically entails acute abdomen, peritonitis and free air in abdominal plain films and/or in computerized tomography. Diagnosis is made both clinically and radiologically.
Following these initial stabilizing measures these patients should be promptly taken to the operating room.
11.4 Patient Selection The Boey’s shock score on admission (i.e. blood pressure below 90 mmHg, ASA class III or IV, and symptoms present for over 24 h) has been found reliable in selecting patients inappropriate for a laparoscopic intervention. If the patient has a Boey’s score of 3, is over 70 years old or if symptoms have been present for over 24 h regardless of Boey’s score, intervention by laparotomy should be considered [5].
11.5 P atient Positioning and Room Preparation Positioning for PPU repair is similar to that used in laparoscopic cholecystectomy. A comfortable supine position with slight reverse Trendelenburg draws the operative field from under the costal margin and avoids leakage of gastric contents into the subphrenic space. Some authors advocate the use of a Lloyd-Davis position allowing for the surgeon to stand between the patient’s legs [4] (Fig. 11.1).
11.3 Pre-operative Management Patients diagnosed with PPU should receive a well-monitored fluid resuscitation as well as intravenous antibiotics [4]. A naso-gastric tube is commonly recommended and narcotics may be administered for pain after the diagnosis is made. J.B. Yuval, MD Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel A. Szold, MD (*) Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel e-mail: [email protected]
11.6 T rocar Position and Laparoscope Angle A 10 mm Trocar should be placed in the umbilicus for the video laparoscope. Additional working ports should be placed in the right and left midclavicular lines at the level of the transpyloric plain [4, 6] (Fig. 11.2). If needed an additional subxiphoid or right lateral subcostal trocar can be inserted for liver retraction. Alternatively a totally internal liver retractor such as the Endolift can be used [7]. An angled laparoscope (30° or 45°) is more commonly preferred for optimal visualization [4].
© Springer International Publishing Switzerland 2017 H.J. Bonjer (ed.),
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