Abstract
Background and aims
Perforated gastroduodenal ulcer represents an emergency situation that requires immediate surgical intervention. Laparoscopic ulcer repair is a feasible and safe procedure, especially in cases of a short duration of ulcer perforation and good clinical condition. However, to be well accepted as a treatment modality, an endoscopic procedure should be as simple as possible. We describe a technique that does not require intra-corporal or extra-corporal knotting.
Patients and methods
Over a 4-year period, we performed 786 diagnostic laparoscopies for various, acute abdominal conditions. We identified 20 gastroduodenal perforations. All ulcers were closed with a one-row running suture (Lahodny) and controlled radiologically on the third postoperative day.
Results
Three different surgeons performed the surgeries. There were no conversions to open surgery. Median operating time was 50 min, and median hospital stay was 9 days. We observed no insufficiency, no wound infection, and no stenosis or persisting peritonitis.
Conclusion
The closure of perforated gastric ulcers with the Lahodny suture is safe and simple to perform.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
The occurrence of perforated peptic ulcer disease is associated with Helicobacter pylori infections, non-steroidal anti-inflammatory agents and elderly patients [1, 2, 3]. Since this group of patients seldom requires complex procedures, which may be associated with increased morbidity and mortality [4, 5, 6], simple closure of the perforation with an omental patch has become the preferred approach for its management in many institutions [7, 8, 9, 10, 11, 12, 13].
Diagnostic laparoscopy is an excellent procedure for the management of acute abdominal conditions [14]. Ulcer perforation is a routine finding in emergency clinics and requires immediate surgical intervention [15, 16, 17]. In addition to conservative treatments [18] or open abdominal surgery, various laparoscopic techniques have also been used to treat this condition over the past few years. There is still, however, disagreement as to the relative merits of laparoscopic ulcer repair. Laparoscopic techniques such as omental patch repair, gelatine sponge, fibrin glue [11, 12] and gastroscopy-assisted methods [19, 20] are time consuming and require extended surgical skills with respect to suturing and knotting techniques [5, 11, 12, 18, 19, 21, 22, 23, 24, 25, 26, 27].
Because perforated peptic ulcers often present as an emergency situation, laparoscopic techniques for their management have to be simple and safe to be acceptable.
We tested the feasibility and safety of a PDS suture (Lahodny suture), a technique familiar to endoscopic hernia-repair surgeons, as a procedure that does not require intra-corporal or extra-corporal knotting.
Patients and methods
In this prospective trial, we performed 768 diagnostic laparoscopies for acute abdominal conditions over a 4-year period. We identified 20 gastroduodenal perforations in this group, that were less than 6 hours old. All 20 patients (mean age 47 years, range 27–73 years) were operated on endoscopically by three different surgeons.
In the same period six patients who presented with gastroduodenal perforations were not included in the study. In one patient, diagnostic laparoscopy revealed perforated gastric cancer, and the intervention was converted to an open approach. In the other five patients, laparoscopy was not used as a diagnostic tool. One patient had perforated gastric carcinoma and four presented with delayed severe peritonitis and septic shock.
Surgical technique and perioperative management
All patients had nasogastric catheter decompression and perioperative therapy with 40 mg omeprazole, amoxicillin and clavulanic acid. Trocar placement was identical to laparoscopic cholecystectomy and was performed according to the French technique, with the surgeon standing between the patient’s legs and the assistant on the left side. In addition to the two 5-mm trocars used for diagnostic laparoscopy (umbilicus and right side of the abdomen, 5-mm camera, Karl Storz, Tuttlingen, Germany), a further 5-mm trocar was placed at the epigastrium, and a 10-mm trocar for the needle holder on the left side of the abdomen. The surgery was started with a biopsy at the ulcer site for histological examination and immediate Helicobacter testing whenever the patient had not undergone gastroscopy preoperatively.
The ulcer was closed with three to five stitches of a monofile running suture, (Lahodny suture, 3.0 PDS II, Ethicon Endo-Surgery, Johnson&Johnson, USA, Fig. 1), which was first pre-laid for orientation. The stitches were applied through the full thickness of healthy tissue. The suture was started a little above the ulcer and was ended one or two stitches below it, so that the ulcer was folded in when the suture was hitched. After the suture had been fixed with a re-absorbable clip (Fig. 2), a wad of omentum was fixed with one or two further stitches of the same suture over the defect, and another clip was applied (Fig. 3). Abdominal lavage was performed with 5–10 l of pre-warmed isotonic saline solution. Two drains were placed at the end of the operation: a Salem drain close to the ulcer and an easy-flow in the Douglas space. Helicobacter eradication (omeprazole, ampicillin, clarithromycin, metronidazole) was started immediately when intraoperative testing was positive.
The duration of antibiotic therapy and abdominal drainage was dependant on the clinical findings. Persistent fever, abdominal pain and intestinal paralysis prolonged the antibiotic therapy. Drains were removed when all secretions were clear. Nasogastral suction was normally removed after the first postoperative day, except in patients with prolonged intestinal paralysis.
All sutures were controlled by contrast radiography on the third day, postoperatively.
Results
Table 1 shows patients’ characteristics and perioperative details. There were ten patients who were being treated with non-steroidal anti-rheumatics (NSARs), 13 were infected with Helicobacter, and 11 patients were smokers.
The surgery was performed by one of three different surgeons on call at the institution. The closure of the ulcer with the running suture was always simple to perform. All patients in whom peptic ulcer perforation was detected laparoscopically were successfully operated on with the described technique. Six patients presented with peritonitis limited to the upper right abdomen, and 14 patients had pus and fibrin throughout the abdomen. There were no intraoperative complications and no conversions to open surgery. Median operating time, including intraoperative lavage and drainage placement, was 50 min (range 35–85 min).
In 14/20 patients, gastric suction was removed quickly on the first day postoperatively and enteral feeding was started with tea. In six patients the gastric tube remained for 3 days because of delayed gastric emptying.
Median length of antibiotic therapy was 3 days (range 1–5) and was dependent on the severity of peritonitis discovered during laparoscopy, postoperative fever and persistent abdominal pain. Drains were removed once the secretions were clear.
After administration of a gastric enema to each patient on the third day postoperatively, the passage of the radiografin revealed no leakage or stenosis. No intra-abdominal abscess or wound infection occurred.
Discussion
Total trauma incurred by a patient during an operation is the sum of the access trauma and the surgical procedure trauma. When the access trauma is relatively large compared with the procedural trauma, the benefit of minimal-access laparoscopic surgery will be maximised [6]. In this regard, ulcer repair may be a condition for which laparoscopic procedures have definite advantages [11, 12, 13, 21, 23, 16, 17, 28]. With diagnostic laparoscopy, the primary access trauma is minimised, and the site and pathology of the perforation can be identified. In addition, the procedure allows for the closure of the perforation and adequate peritoneal lavage without a large upper abdominal incision. Nevertheless, laparoscopic ulcer repair does not seem to be widely used in daily practice.
After the initial, anecdotal reports of laparoscopic treatments of a perforated peptic ulcer, various techniques of ulcer closure have been described. Walsh et al. [29] begin with diagnostic laparoscopy. If the ulcer is already covered by omentum, the authors generally restrict themselves to peritoneal drainage and lavage, since they consider it the most important part of any intervention. Other techniques of ulcer repair are: suturing with single stitches [8, 30], closure with gelatine sponges and fibrin glue [11, 12], sutured or stapled omental patch repair [10, 11, 12, 17, 18, 21, 22, 23, 24, 26, 27] and gastroscopy-aided insertion of the ligamentum teres hepatis or omental plug [19, 20].
All these techniques are relatively time consuming, when compared with open surgery. Median operating times reported have varied between 80 and 120 min (Table 2). In addition, most of these procedures require advanced surgical skills, especially with respect to suturing and knotting techniques and extended preoperative planning (gelatine sponge and fibrin glue repair, gastroscopy-aided techniques). The reported complication rates are acceptably low, if the surgeons restrict laparoscopic repairs to patients in relatively good clinical condition who have small perforations of short duration [8, 31].
All these reports show that laparoscopic ulcer repair is, in principle, possible, but a definitive advantage over the established open techniques has not been shown. Moreover, ulcer perforation often represents an “out-of-hours” emergency that must be performed by “any” surgeon on call. The technique, therefore, should be simple to perform, and the results comparable to open techniques [29].
In 1997, Siu et al. first reported on the closure of a perforated gastroduodenal ulcer with one single stitch, longitudinally through the perforation [6]. In a recently published, randomised trial [30], the authors showed that this very simple technique was highly effective. This is the first randomised trial where the median operating times in the laparoscopic group were significantly shorter than in the open surgery group (42 vs 52 min). The laparoscopic approach was associated with an impressively low leakage rate (1/63). Conversion to open surgery was necessary in only 9/63 patients who had perforated, non-pyloric, gastric ulcers and unidentifiable perforations with a diameter larger than 10 mm. Patients in the laparoscopic group were discharged earlier and recovered significantly faster (return to work 10.4 vs 26.1 days).
In our series, we selected the suture-closure method because it is based on the principle of conventional open repair. Our method differed from others because we used a monofile running suture (Figs. 1, 2, 3) familiar to endoscopic hernia surgery, which does not require any intra-corporal or extra-corporal knotting. Owing to the monofile structure of the file, 3–5 stitches can be placed with a maximum overview and the ulcer easily closed in a very controlled manner.
Over 4 years, three different surgeons who covered the 24-hour emergency unit in our department used this technique successfully. There were no major intraoperative difficulties that resulted in excess surgery time or conversion to open surgery. Compared with the single-stitch technique [6, 30], the operating time seems to last slightly longer with our technique, but, in contrast to Siu et al., we installed abdominal drains and performed a very meticulous lavage of the whole abdominal cavity.
The advantage of the monofile running suture may lie in the more meticulous closure of the perforation. In the case of severe peritonitis, when the overview is poor, placement and knotting of single stitches may provoke bleeding that can jeopardise the controlled performance of the intervention [32]. In these cases, and when the edges of the perforation are rigid, the closure of the defect may be easier with 3–5 stitches of a monofile running suture. In fact, we had no conversion to open surgery. All of our patients were controlled on the third day postoperatively by contrast radiography, and we did not observe any leakage. However, the number of patients treated in this trial was relatively low. Consequently, we cannot make a serious prediction about expectable complication and leakage rates.
Patients with large ulcers, prolonged anamnesis and/or reduced conditions due to severe peritonitis may not present a good case for laparoscopic repair, but the discussion is still controversial. In several studies, the severity of the disease and reduced general conditions were prognostic factors for postoperative complications (i.e. leakage, persisting peritonitis, intra-abdominal abscess and sepsis) [10, 33]. For this reason, we restricted ourselves to patients with acute history. Whether a delay of more than 6 hours is a contraindication for laparoscopic repair is not clear and cannot be answered by our study. However, 14 of our patients presented with severe peritonitis, with pus and fibrin covering the whole abdominal cavity, and laparoscopic surgery was successful, nevertheless. But, like Arnaud et al., Katkhouda et al. and Lagoo and Pappas [8, 34, 35], we find that the best indication for the use of the laparoscopic technique is in patients with acute abdominal pain, where the pathological condition is demonstrated or diagnosed by laparoscopy, and should be restricted to patients in relatively good general condition (ASA1–3).
In conclusion, laparoscopic ulcer repair with the Lahodny suture is safe and simple to perform. Compared with more sophisticated endoscopic techniques, it is highly effective and results in significantly reduced operating time.
References
Lanas A, Serrano P, Bajador E, Esteva F, Benito R, Sainz R (1997) Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology 112:683–689
Sánchez-Bueno F, Marín P, Ríos A, Aguayo JL, Robles R, Piñero A, Fernández JA, Parrilla P (2001) Has the incidence of perforated peptic ulcer decreased over the last decade? (with invited commentary) Dig Surg 18:444–448
Svanes C, Salvesen H, Stangeland L, Svanes K, Soreide O (1993) Perforated peptic ulcer over 56 years: time trends in patients and disease characteristics. Gut 34:1666–1671
Blomgren LG (1997) Perforated peptic ulcer: long-term results after simple closure in the elderly. World J Surg 21:412–414
Bornman PC, Theodorou NA, Jeffery PC, Marks IN, Essel HP, Wright JP, Terblanche J (1990) Simple closure of perforated duodenal ulcer: a prospective evaluation of a conservative management policy. Br J Surg 77:73–75
Siu WT, Leong HT, Li MKW (1997) Single stitch laparoscopic omental patch repair of perforated peptic ulcers. J R Coll Surg Edinb 42:92–94
Alamowic B, Aouad K, Sellam P, Fourmestraux J, Gasne P, Bethoux JP, Boillot JL (2000) Laparoscopic treatment of perforated duodenal ulcer. Gastroenterol Clin Biol 24:1012–1017
Arnaud JP, Tuech JJ, Bergamaschi R, Pessaux P, Regenet N (2002) Laparoscopic suture closure of perforated duodenal peptic ulcer. Surg Laparosc Endosc Percutan Tech 12:145–147
Cougard P, Barrat C, Gayral F, Cadiere GB, Meyer C, Fagniez L, Bouillot JL, Boissel P, Samama G, Champault G (2000) Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery. Ann Chir 125:726–731
Druart ML, Van Hee R, Etienne J, Cadiere GB, Gigot JF, Legrand M, Limbosch JM, Navez B, Tugilimana M, Van Vyve E, Vereecken L, Wibin E, Yvergneaux JP (1997) Laparoscopic repair of perforated duodenal ulcer: a prospective multicenter clinical trial. Surg Endosc 11:1017–1020
Lau WY, Leung KL, Zhu XL, Lam YH, Chung SC, Li AK (1995) Laparoscopic repair of perforated peptic ulcer. Br J Surg 82:814–816
Lau WY, Leung KL, Kwong KH, Davey IC, Robertson C, Dawson JJ (1996) A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture and sutureless technique. Ann Surg 224:131–138
Lee FYJ, Leung KL, Lai PBS, Lau JWY (2001) Selection of patients for laparoscopic repair of perforated peptic ulcer. Br J Surg 88:133–136
Paterson-Brown S (1993) Emergency laparoscopic surgery. Br J Surg 80:279–283
Nathanson LK, Easter DW, Cuschieri A (1990) Laparoscopic repair/toilet of perforated peptic ulcer. Surg Endosc 4:232–233
So JB, Cum CK, Fernandez ML, Goh P (1996) Comparison of laparoscopic and conventional omental patch repair for perforated duodenal ulcer. Surg Endosc 10:1060–1063
Sunderland GT, Chrisholm EM, Lau WY, Chung SSC, Li AKC (1992) Laparoscopic repair of perforated peptic ulcer. Br J Surg 79:785
Crofts TJ, Park KGM, Steel RJC, Chung SSC, Li AKC (1989) A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med 320:970–973
Costalat G, Dravet F, Noel P, Alquier Y, Vernhet J (1991) Coelioscopic treatment of perforated gastroduodenal ulcer using the ligamentum teres hepatis. Surg Endosc 5:154–155
Pescatore P, Halkic N, Calmes JM, Blum A, Gillet M (1998) Combined laparoscopic–endoscopic method using an omental plug for therapy of gastroduodenal ulcer perforation. Gastrointest Endosc 48:411–414
Darzi A, Cheshire NJ, Somers SS, Super PA, Guillou PJ, Monson JR (1993) Laparoscopic omental patch repair of perforated duodenal ulcer with an automated stapler. Br J Surg 80:1552
Miserez M, Eypasch E, Spangenberger W, Lefering R, Troidl H (1996) Laparoscopic and conventional closure of perforated peptic ulcer. A comparison. Surg Endosc 10:831–836
Naesgard JM, Edwin B, Reiertsen O, Trondsen E, Fearden AE, Rosseland AR (1999) Laparoscopic and open operation in patients with perforated peptic ulcer. Eur J Surg 165:209–214
Nassar A (1994) Laparoscopic omental patch repair of perforated duodenal ulcer with automated stapler. Br J Surg 81:1393
Bergamaschi R, Marvik R, Johnsen G, Thoresen JE, Ystgaard B, Myrvold HE (1999) Open vs laparoscopic repair of perforated peptic ulcer. Surg Endosc 13:679–682
Tate JJ, Dawson JW, Lau WY, Li AK (1993) Sutureless laparoscopic treatment of perforated duodenal ulcer. Br J Surg 80:235
Urbano D, Rossi M, De Simone P, Berloco P, Alfani D, Cortesini R (1994) Alternative laparoscopic management of perforated peptic ulcers. Surg Endosc 8:1208–1211
Elio A, Veronese E, Dal Dosso I, Orcalli F (2002) Laparoscopic approach in the treatment of perforated gastroduodenal ulcer. Chir Ital 54:51–53
Walsh CJ, Khoo DE, Motson RW (1993) Laparoscopic repair of perforated peptic ulcer. Br J Surg 80:127
Siu WT, Leong HAT, Law BK, Chau CH, Li AC, Fung KH, Tai YP, Li MK (2002) Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 235:313–319
Michelet I, Agresta F (2000) Perforated peptic ulcer: laparoscopic approach. Eur J Surg 166:405–408
Wemyss-Holden S, White SA, Robertson G, Lloyd D (2002) Color coding of sutures in laparoscopic perforated duodenal ulcer: a new concept. Surg Laparosc Endosc Percutan Tech 12:177–179
Bulut O, Rasmussen C, Fischer A (1996) Acute surgical treatment of complicated peptic ulcers with special reference to the elderly. World J Surg 20:574–577
Katkhouda N, Mavor E, Mason RJ, Campos GM, Soroushyari A, Berne TV (1999) Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients. Arch Surg 134:845–848
Lagoo SA, Pappas TN (2002) Laparoscopic repair for perforated peptic ulcer. Ann Surg 235:320–321
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Köninger, J., Böttinger, P., Redecke, J. et al. Laparoscopic repair of perforated gastroduodenal ulcer by running suture. Langenbecks Arch Surg 389, 11–16 (2004). https://doi.org/10.1007/s00423-003-0427-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00423-003-0427-x