ANNALS OF SURGERY

Vol. 221, No. 3, 236-240

© 1995 J. B. Lippincott Company

Laparoscopic Omental Patch Repair

for Perforated Peptic Ulcer
Masao Matsuda, M.D., Motoharu Nishiyama, M.D., Tsunekazu Hanai, M.D., Satomi Saeki, M.D.,
and Toshiaki Watanabe, M.D.

From the Department of Surgery, Chukyo Hospital, Nagoya, Japan

Objective
The authors' initial experience with laparoscopic omental patch repair for perforated peptic ulcer is
documented. Its results are compared with those of other procedures and follow-up study is
reviewed.

Summary Background Data

Since the advent of H2-antagonists, the usefulness of simple closure of a perforated peptic ulcer is
increasing, and improvements in laparoscopic surgery have made possible minimally invasive
surgery for perforated ulcer.

Methods
From December 1992 to February 1994, laparoscopic omental patch repair followed by use of H2-
antagonists was performed successfully in 11 patients. Fifty-five patients underwent other surgical
procedures for perforated peptic ulcers (conventional open omental patch: 4, selective vagotomy
in combination with antrectomy: 24, distal gastrectomy: 27).

Results
The average operation time was 135 minutes. Administration of postoperative pain medication
was reduced remarkably (0.9 times per patient), and all patients recovered rapidly. No serious
postoperative complications were recorded. After a mean period of 11 months, the postoperative
evaluation was satisfactory for all patients, and no ulcer recurrence was found.

Conclusions
In perforated peptic ulcer disease, laparoscopic omental patch repair offers a number of
advantages. Because no upper abdominal incision is made, there is decreased postoperative
pain, and the patient rapidly recovers with fewer and less severe complications. Although the
procedure requires a surgeon with particular expertise in endoscopic suturing technique,
surgeons familiar with laparoscopic cholecystectomy can readily perform it after some practice.
The authors' preliminary experience suggests that this is a minimally invasive procedure for
perforated peptic ulcer that offers an attractive alternative to open surgery.

Since the advent of H2-antagonists, supplemented re-
cently by omeprazole, the frequency of the use ofsurgical
Address reprint requests to Masao Matsuda M.D., Department of Sur-
gery, Chukyo Hospital, 1-1-10 Sanjo, Minami-ku, Nagoya, Japan.
Accepted for publication August 16, 1994.
236
procedures for intractable peptic ulcer has decreased dra-
matically.' The use of simple closure of perforated peptic
ulcer, in combination with postoperative use of H2-
blocking drugs, also has been increasing.2 Laparoscopic
surgery has revolutionized the practice of cholecystec-
tomy and has led to the development of a wide range of
 f/,.i:-E\^1l
Vol. 221 * No. 3 Laparoscopic Repair for Perforated Ulcer 237

Table 1. BACKGROUNDS OF PATIENTS

Laparoscopic Selective Vagotomy
Omental Patch Open Omental Patch with Antrectomy Gastrectomy
Preoperative Data (n = 11) (n = 4) (n = 24) (n = 27)
Age (yrs) 19-81 33-66 16-65 20-79
Average 39.8 49.5 33.3 48.7
Male:female 10:1 4:0 22:2 24:3
Shock state patients 0 0 1 1
Duration of perforation (hrs) 4-21 6-19 3-20 3-48
Average 8.4 14.0 6.9 10.6

laparoscopic surgical procedures. Progress currently can SURGICAL TECHNIQUE OF

be said to include this minimally invasive surgical proce-
dure for perforated peptic ulcer.
This report documents our initial experience with lap-
aroscopic omental patch repair for perforated peptic ul-
cers. Its results are compared with those of other proce-
dures, and follow-up study is reviewed.
PATIENTS AND METHODS
From December 1992 through February 1994, 14 pa-
tients underwent laparoscopic omental patch repair for
perforated peptic ulcers. The procedure was completed
successfully in 11 patients (duodenal ulcers: 10, gastric
ulcer: 1) In three operations, the procedure was changed
to conventional open surgery because of omental adhe-
sion after appendectomy, perforation of the posterior
wall of the stomach, and a large perforation of a giant
gastric ulcer. In addition, two cases of colorectal perfora-
tions were diagnosed laparoscopically in this minimally
invasive way. Ten men and one woman had successful
procedures, with a mean age of 39.8 years (range 19-81
years). No patient suffered preoperative shock; however,
an 8 1-year-old patient had chronic cardiac insufficiency
that required hospitalization three times.
From June 1983 to December 1993, 55 patients un-
LAPAROSCOPIC OMENTAL
PATCH REPAIR
The patients were placed in the supine position with
legs spread apart. The operating surgeon stood at the pa-
tient's right side, with an assistant stationed at the pa-
tient's left side and a second assistant positioned between
the patient's legs.
A disposable insufflation needle was introduced just
below the umbilicus, and pneumoperitoneum was estab-
lished using CO2. Intraperitoneal pressure was main-
tained at or below 12 mm Hg. A first 10-mm port was
inserted just below the umbilicus and used to introduce
the laparoscope. Then, under direct vision, the remain-
ing trocars were inserted through the abdominal wall
(Fig. 1). A second 10-mm port, inserted below and to the
left of the xiphoid, was used to introduce forceps, retrac-
tor, or aspiration-probe by the first assistant. Third and
fourth 5-mm ports were inserted in the upper right quad-
1
t :f i : : :f.g.l
.: ... -:S,5E i. |
I
{
d --; \
--.:.0\
;fj ....i... \ 1'1N
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s

derwent other surgical procedures for perforated peptic

ulcers. These included 4 cases with conventional open
omental patch, 24 with selective vagotomies in combi- v ........ 1
3.... 0.... I
t

\
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...,
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nation with antrectomies, and 27 patients with distal gas- \ if iE.D i,
1 st assistant
trectomies. The details on patients' background of each
group are shown in Table 1. operator
The results of these surgical procedures were recorded
with reference to operative time, postoperative pain
medication, period of hospitalization, dietary condition
after operation, and morbidity and mortality rates. Ten
of the 11 patients who underwent laparoscopic omental
patch repair were observed for follow-up for a mean pe- 2nd assistant
riod of 11 months (range 3-18 months). Figure 1. Sites of insertion of ports
238 Matsuda and Others Ann. Surg. * March 1995

and maneuvering the omentum to the perforation site

Figure 2. The first suture is passed through the duodenal wall and apex
of the omentum, and knotted with four instrumental ties intracorporeally.
rant at the anterior axillary and midclavicular line, for
insertion of grasping forceps and needle holders by the
operator. On occasion, a fifth additional 5-mm port was
inserted in the upper left quadrant at the midclavicular
line, which allowed insertion of an atraumatic retractor
or a Babcock clamp to retract the gastric antrum down-
ward to expose the first part of the duodenum. A sixth
5-mm port was inserted in the right lower quadrant for
irrigation and drainage of the pelvis fossa.
The abdominal cavity was first explored by video la-
paroscope assisted by the atraumatic retractor, to deter-
mine the degree of peritoneal soiling and the perforation
site. Soiled ascitic fluid usually is present in the upper
right quadrant and the pelvis. Acute duodenal perfora-
tions usually were covered by the undersurface of the
liver and were identified easily with upward displace-
ment of the liver using a retractor. The peritoneal cavity
was irrigated with 3 to 5 liters of warm saline, and any
increase of intraperitoneal pressure was noted. Pulling
without tension, the perforation was then closed. The
omentum was plugged into the perforation with two in-
terrupted sutures using a 3-0 polyglactin 9 10 suture (Vi-
cryl, Ethicon, Somerville, NJ) on J-shaped needle, which
was reconstructed from ordinary curved needle. The first
suture was passed through the full thickness of the duo-
denal wall and the apex of the omentum and knotted
intracorporeally with four instrumental ties (Fig. 2). The
second suture was passed through the seromuscular layer
of the duodenal wall and a piece of omentum and an-
chored by double clipping (Endo Clip: U.S. Surgical,
Norwalk, CT) rather than knotting. After closure of the
perforation, the abdominal cavity was irrigated thor-
oughly again with warm saline until no more stains could
be observed. Silicon sheet drains were left in the right
subhepatic pouch, close to the perforation and the pelvis
fossa. The nasogastric tube was left in place until intesti-
nal peristalsis was recognized. All patients received H2-
antagonist intravenously immediately after operation,
followed by long-time oral medication.
RESULTS
The outcomes of the four surgical procedures are
shown in Table 2. The average operative time was short-
est in the open omental patch method (93.7 min). The
average operative time of laparoscopic omental patch
(135 min) was less than for selective vagotomy with an-
trectomy (224 min) or gastrectomy (186 min). Postoper-
ative pain control was achieved mainly with intramuscu-
lar injection of pentazocine. The administration fre-
quency of pain medication was reduced remarkably in
laparoscopic omental patch repair (0.9 times per patient
on an average) compared with the other procedures (2.0,
4.0, and 4.7 times per patient). There was no significant
difference between the durations of nasogastric suction
in these four procedures. The average hospitalization

Table 2. COMPARISON OF THE OPERATIVE PROCEDURES

Laparoscopic Open Selective Vagotomy
Omental Patch Omental Patch with Antrectomy Gastrectomy
(n = 11) (n = 4) (n = 24) (n = 27)

Average operation time (min) 135 93.7 224 186

Minimum-maximum 102-160 55-110 153-355 85-325
Average times of pain control 0.9 2.0 4.0 4.7
Minimum-maximum 0-3 0-4 0-9 0-14
Nasogastric tube removal 3.0 POD 3.7 POD 3.0 POD 3.0 POD
Minimum-maximum 2-5 2-5 2-5 2-5
Taking meals at discharge 99.3% 100% 84.2% 75.5%
Minimum-maximum 93-100 100-100 30-100 35-100
Average hospitalization (days) 17.0 17.3 19.1 23.9
Minimum-maximum 13-23 14-22 10-30 20-79
Vol. 221 * No. 3 Laparoscopic Repair for Perforated Ulcer 239

The details of postoperative complications are shown

Table 3. POSTOPERATIVE
COMPLICATIONS
in Table 3. The morbidity rate was 9. 1 % in laparoscopic
omental patch, 0% in open omental patch, 12.5% in se-
Laparoscopic omental lective vagotomy with antrectomy, and 26.0% in gastrec-
patch 9.1% (1/11) tomy. In cases with laparoscopic omental patch, the
Atrial fibrillation aforementioned 81-year-old patient developed tempo-
Open omental patch 0% (0/4)
Non rary atrial fibrillation postoperatively, but no other post-
Selective vagatomy with operative complications were recorded. One patient died
antrectomy 12.5% (3/24) 12 days after distal gastrectomy due to sepsis, and the
Intraperitoneal bleeding overall mortality rate was 1.5% (1/66).
Anastomotic stenosis 2 In a follow-up study of 10 of patients with laparo-
Distal gastrectomy
Sepsis 1 (died) 26.0% (7/27) scopic omental patch, 8 patients still were taking H2-re-
Pneumonia 2 ceptor antagonists and 2 had discontinued them on their
Wound infection own. Postoperative evaluation, according to the criteria
1
Wound rupture of Visick (1948), was satisfactory in all patients (no
1
Subphrenic abscess symptoms or only slight periodic dyspepsia, which was
1
Atrial fibrillation
easily controlled), and there was no ulcer recurrence.
Body weight after operation increased or remained un-
changed in all patients.
days for laparoscopic omental patch repair I(1 7.0 days)
was shorter than for the other procedures ( 1 7. 3, 19.l,and
23.9 days). Almost all patients had recoveredlenough to DISCUSSION
be discharged within 7 days after laparoscop ic omental
patch repair. However, patients' education regarding In perforated peptic ulcer disease, laparoscopic omen-
postoperative medication and postoperative gastroduo- tal patch repair offers a number of advantages. Because
denal fiberscopic examination called for further hospi- no upper abdominal incision is made, there is decreased
talization. The ability to ingest meals on disc]harge from postoperative pain, and the patient rapidly recovers with
the hospital was excellent for patients after laLparoscopic fewer and less severe complications. Digestion is suffi-
and open omental patch repair (99.3% and 00%) com- cient after this operation, with no resection of the stom-
pared with selective vagotomy with antrectormy (84.2%) ach. Operative scars are minimal and resolve the aes-
or gastrectomy (75.5%). In nine patients w,ith laparo- thetic concerns, especially those of young patients. The
scopic omental patch repair, an endoscopic e Lamination perforation site of the gastrointestinal tract can be diag-
was performed on the 0th to 16th postoperaltive day. In nosed laparoscopically at the beginning ofthis procedure
eight of these cases, the ulcers already had healed; an in a minimally invasive way.
open ulcer was recognized in one case. There has been controversy as to the preferred opera-

Table 4. DEFINITIVE SURGERY AFTER SIMPLE CLOSURE OF PERFORATED PEPTIC ULCER

Simple Closure Only Simple Closure + H2-Antagonists
No. of Definitive No. of Definitive
Reporter Year Cases Surgery (%) Cases Surgery (%)
Skovgaard 1977 111/156 71
Heuman et al. 1983 13/53 25
Gillen et al. 1986 16/28 57.1 15/26 57.6
Welch et al. 1986 27/107 20.5
Simpson et al. 1987 3/25 12 0/30 0
King and Ross 1987 23/86 27
Bose and Thakur 1988 10/46 21.7
Macintyre and Miller 1990 43/97 44.3 14/58 24.1
George and Smith 1990 16/61 26 0/14 0
Bormann et al. 1990 21/113 18.6
Koh 1992 3/46 6.5
Hamby et al. 1993 9/33 27
Total 271/692 39.2% 53/287 18.5%
240 Matsuda and Others
tive procedure for perforated peptic ulcer-simple clo-
sure or definitive surgery. Justification for definitive sur-
gery is based largely on reports of a high incidence of
recurrent ulceration and further operation after simple
closure. However, recent reports also have shown that
simple closure with immediate administration of H2-an-
tagonists has been associated with a reduction in the
number of subsequent definitive operations (Table 4).
According to these reports, the need for subsequent de-
finitive surgery was 18.5% after simple closure and post-
operative administration of H2-receptor antagonists,
compared with 39.2% after simple closure alone. In this
study, no ulcer recurrence was encountered after a mean
follow-up period of 11 months. The availability of H2-
antagonists currently offers the opportunity to reappraise
the role of simple closure for perforated peptic ulcer.
We believe that omental patch closure with suturing
and knotting is a highly reliable method, and very appli-
cable with a wide range of laparoscopic procedures.
There are two techniques of knot tying, intracorporeal
tying using forceps3-6 and extracorporeal tying using a
knot pusher.7"8 These techniques seem equally effective,
but they take time and require special skills of surgeons.
Some variations of procedures have been reported.
Mouret and colleagues, who first introduced laparo-
scopic closure ofperforated peptic ulcer, reported sealing
the perforation with an omental patch held in position
by fibrin glue.9 Tate et al. presented a sutureless method
using a gelatin sponge plug and fibrin sealant.10 We have
adopted a clipping technique (Endo Clip) in place of
knotting in a second omental patch suture, and in the
latest case, Endo Hernia (U.S. Surgical) stapling was used
instead of suturing.
Ann. Surg. * March 1995
CONCLUSION
Although the procedure presented requires a surgeon
with particular expertise in endoscopic suturing tech-
nique, surgeons familiar with laparoscopic cholecystec-
tomy can readily perform it after some practice. The op-
eration currently takes longer than open patch repair,
but with increasing experience and practice, less time
will be needed. Our preliminary experience suggests that
laparoscopic omental patch repair followed by admin-
istration of H2-receptor antagonists is minimally inva-
sive surgery for perforated peptic ulcer and offers an at-
tractive alternative to open surgery.
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