We enrolled 21 consecutive patients who underwent primary repair with omentopexy for duodenal ulcer perforation between March, 2011 and May, 2012 at Hanyang University Guri Hospital. We retrospectively reviewed the prospectively collected data. In this study, experienced surgeons were defined as those who had abundant experience in laparoscopic surgery and other major operations as the operating surgeon. One experienced surgeon had performed 139 laparoscopic gastrectomies to treat gastric cancer by March, 2010.(25)

There were no laparoscopic explorations during the study period and there were no contraindications to perform laparoscopic surgery. Laparoscopic primary repair was carried out regardless of time from the onset of symptoms, previous laparotomy, old age, and comorbidity. The choice of primary repair was decided by an intra-operative assessment of the perforation size. During the same period, five patients who were diagnosed with giant duodenal ulcer perforation (>2 cm) underwent laparoscopic distal gastrectomy with truncal vagotomy. These patients were excluded from the study.(18)

Each patient was placed in thereverse Trendelenburg position. A carbon dioxide pneumoperitoneum was formed from the umbilical port, and pressure was maintained between 12 and 15 mmHg. Two 12 mm trocars and one 5 mm trocar (ENDOPATH Xcel Bladeless Trocar) were positioned as described in Fig. 1A.

After all the trocars were inserted, the size of the perforation was measured by intra-operative assessment. If the perforation was not much bigger than 2 cm, we carried out a laparoscopic primary repair with omentopexy. To minimize spillage of gastric, biliary, and pancreatic contents from the perforation site, we closed the perforation site before peritoneal irrigation.

Extracorporeal knot tying was used to make it easier for the operator to perform the suturing. Our technique consists of several steps. First, undetached black silks (3-0, 26 mm, 75 cm, MERSILK, ETHICON®) were used to close the perforation site. Closure of the perforation site was performed to avoid the possibility of the detached needle dropping into the abdominal cavity. Second, the needle was prevented from dropping through the trocar during insertion and extraction by grasping the thread 2 cm below the needle (Fig. 1B). This thread was then moved into the right lower trocar (Fig. 1C). Third, the needle was held just below the swage to perform suture repair of full thickness around the perforation site (Fig. 1D, 2A). In the process of extracting the needle and thread from the suture site, a pulley principle was used to minimize injury to the inflamed tissues. Because the smooth surface of the grasper body changes the direction of the tension force in the thread and decreases the force, it was possible to extract the needle easily (Fig. 2B). Before performing extracorporeal knot tying, this thread was extracted from the right upper trocar. The detached thread was extracted again through the right upper trocar to make a knot. After tying, a knot was made just above the perforation site by pushing a knot pusher through the right upper trocar (Fig. 2C).

After primary closure of the perforation site, the contaminated abdominal cavity was irrigated with a large volume of saline (usually 1 or 2 L) to avoid the accumulation of infected fluid and other debris. Once irrigation was complete, a large volume of omentum was reinforced above the primary suture site by extracorporeal knot tying (Fig. 2D).

A nasogastric tube was inserted in order to prevent spillage of the stomach contents into the peritoneal cavity at the time of diagnosis of the duodenal ulcer perforation. Broad spectrum antibiotics were used until all signs of peritoneal irritation disappeared.

After surgery, the nasogastric tube was maintained until it was safe to remove it, as indicated by upper gastrointestinal imaging (UGI) using gastrografin. Depending on the return of bowel activity, UGI examination was performed on postoperative day 3~5. An intravenous proton pump inhibitor was injected during the fasting period and theoral proton pump inhibitor was changed after starting a diet, and continued for 8 weeks.

During the operation, a laparoscopic biopsy of the ulcer was performed if possible. If this was not possible due to inflamed ulcer tissues, a follow-up gastrofiberscopy was performed to evaluate the state of the ulcer.

Clinical data obtained from medical records included patient age, gender, body mass index (BMI), and American Society of Anesthesiologist (ASA) score. Early surgical outcomes included operation time, overall postoperative complications, day of normalization of leukocytosis, day of commencement of a soft diet, number of administered analgesics, and postoperative hospital stay.

Postoperative complications were defined as any condition requiring conservative or surgical treatment. Severe postoperative complications were defined as those that required management by an endoscopic or interventional procedure or a re-operation (expanded classification, over level 3).(26)

In this study, a liquid diet was started after confirming the safety of the suture site by performing UGI between postoperative days 3 and 5. The soft diet was started when patients felt comfortable enough to consume a liquid diet twice, consecutively. Patients were discharged if they had no problems eating a soft diet, showed an absence of inflammatory conditions including leukocytosis, unstable vital signs and abrupt onset abdominal pain, and if they were generally comfortable. The final decision regarding discharge was left up to each patient.

The clinical characteristics of the patients in this study are presented in Table 1. Twenty-one patients, 16 men and five women, presenting with duodenal ulcer perforation were treated with laparoscopic primary repair with omentopexy. The median age was 53 years (19~82 years). Median BMI at the time of operation was 21.7 (14.3~31.2). Ten of the 21 patients showed ASA class 2, 3. Fourteen patients underwent the operation more than 24 hours after the onset of symptoms. Two patients arrived at our institution in a state of shock.

Details of early surgical outcomes are listed in Table 2. There was no conversion to open surgery and no postoperative mortality in any patients. Postoperative complications occurred in one patient (4.7%). The median operation time was 45.0 minutes. The median day of commencement of a soft diet was 6.0 days. The mean number of administered analgesics was 1.3 during the postoperative period. The duration of the postoperative hospital stay was 8.0 days.

A 58-year-old male patient was operated on due to a duodenal ulcer perforation. The time period between onset of symptoms and diagnosis was over 48 hours. Before being transferred to our hospital, he was hospitalized in a specialized dementia hospital because of alcohol dementia. Based on operative findings, the size of the perforation measured about 2 cm. The whole abdominal cavity had been severely contaminated by infected bowel contents. Two stitches were used to close the perforation. The operation took 1 hour from skin incision to skin closure. The first postoperative UGI series showed a contrast leakage from the suture site, although there were no clinical signs of leakage during the recovery period. Radiologic leakage disappeared by postoperative day 15. After confirming closure of the perforation, the patient started a soft diet on postoperative day 17. He was discharged from the hospital on postoperative day 18.