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Laparoscopic treatment of perforated peptic ulcer Johan Lange Dep Surgery Erasmus University Medical Center Rotterdam.

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Presentation on theme: "Laparoscopic treatment of perforated peptic ulcer Johan Lange Dep Surgery Erasmus University Medical Center Rotterdam."— Presentation transcript:

1 Laparoscopic treatment of perforated peptic ulcer Johan Lange Dep Surgery Erasmus University Medical Center Rotterdam

2 Perforated peptic ulcer


4 Perforated peptic ulcer famous fatalities Napoleon James Joyce Rudolph Valentino

5 Perforated peptic ulcer Acute abdomen (De Dombal n=30.000)  Appendicitis 28%  Cholecystolithiasis 9.7%  Occluded small intestine 4.1%  Gynecologic disorders 4.0%  Acute pancreatitis 2.9%  Urologic diagnosis 2.9%  Perforated peptic ulcer 2.5% (5-10 pro year)  Other diagnosis 1.5%  No diagnosis >40%

6 Perforated peptic ulcer Pathology  Most often chronic ulcer  50%: sealed off  Location: most often anterior juxtapyloric  Mean diameter: 5mm (>1cm=giant ulcer: rare)  10%: perforated gastric ulcer)

7 Perforated peptic ulcer morphology related to location juxta-pyloric ulcer: small, healthy border gastric ulcer at lesser curvature: large, fibrotic edematous border (ulcus callosum)

8 Perforated peptic ulcer perforated gastric carcinoma

9 Perforated peptic ulcer sealing off by left liver half

10 Perforated peptic ulcer sealing off by segment IV

11 Perforated peptic ulcer sealing off by left liver lobe X: free air below diaphragm in this patient

12 Perforated peptic ulcer fibrinous peritonitis+parahepatic collection

13 Perforated peptic ulcer ulcer visible after lifting left liver lobe

14 Perforated peptic ulcer Bacteriology  <48h in 50%: sterile peritonitis; in other 50%: grampositive peritonitis  >48h: infected peritonitis, most often grampositive initially, later gramnegative

15 Perforated peptic ulcer cause of death: peritonitis Pre-antibiotics-mortality: 75%

16 Perforated peptic ulcer subphrenisch abces

17 Perforated peptic ulcer Boey prognostic parameters  Age  Duration of symptoms  Shock  ASA III-IV  Diameter of ulcer

18 Perforated peptic ulcer Diagnosis


20 Perforated peptic ulcer


22 Perforated peptic ulcer Diagnosis  1) X-thorax/abdomen in upright position  If negative:  2) CT with oral contrast

23 Perforated peptic ulcer duration of postoperative pneumoperitoneum  X: <6 days: 90%  CT: <6 days: 50%; <18 days: 100%

24 Perforated peptic ulcer Operative therapy (history)  1892 resection: Heusner  1894 oversewe: Dean  1937 omental patch: Graham  1990 laparoscopy: Mouret (1947 Taylor: conservative)

25 Perforated peptic ulcer Operative therapy (closure+lavage)  Only after resuscitation  Closure+lavage  Postoperative gastric aspiration  Acid suppression (PPI’ s)  Antibiotics

26 Perforated peptic ulcer laparoscopic closure


28 Perforated peptic ulcer (stapler-fixation of omentum)

29 Perforated peptic ulcer rendez vous omental patch

30 Perforated peptic ulcer Graham 1937: omental patch plication (without primary closure of ulcer) Kathkouda et al 1993: laparoscopic Graham omental patch

31 Perforated peptic ulcer 3 stitch-Graham omental patch Lam et al. Surg Endosc 2005; 19: 1627-30 Distance ulcer>1cm

32 Perforated peptic ulcer 3 stitch-Graham omental patch

33 Perforated peptic ulcer Flat tire test

34 Perforated peptic ulcer drain?

35 Perforated peptic ulcer operative therapy: abdominal complications  Re-leakage: 10%  Intra-abdominal abscess: 3%

36 Perforated peptic ulcer operative therapy: results  Mortality: 0-8%  Morbidity: 13-23%  Parameters: ASA-, Boey scores  In general: results correlated with duration of symptoms, ulcer diameter, age


38 1: World J Surg. 2005 Oct;29(10):1299-310. Related Articles, Related Articles, Links Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. Lunevicius R, Morkevicius M. Lunevicius RMorkevicius M World J Surg 2005; 29: 1299-310 2nd Department of Abdominal Surgery, Clinic of General and Plastic Surgery, Orthopaedics, and Traumatology, Vilnius University Emergency Hospital, Vilnius University, Siltnamiu Street 29, LT- 04130 Vilnius, Lithuania. The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

39 Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Lunevicius R, Morkevicius M. Lunevicius RMorkevicius M Br J Surg 2005; 92: 1195-207 Clinic of General and Plastic surgery, Orthopaedics and Trauma surgery, General Surgery Centre, Vilnius University Emergency Hospital, 29 Siltnamiu Street, LT-04130, Vilnius, Lithuania. BACKGROUND: The advantages of laparoscopic over open repair for perforated peptic ulcer are not as obvious as they may seem. This paper summarizes the published trials comparing the two approaches. METHODS: Two randomized prospective, five non-randomized prospective and eight retrospective studies were included in the analysis. Relevant trials were identified from the Medline/Pubmed database and the reference lists of the retrieved papers were then analysed. The outcome measures used were operating time, postoperative analgesic requirements, length of hospital stay, return to normal diet and usual activities, and complication and mortality rates. Published data were tested for heterogeneity by means of a chi2 test. Meta-analysis methods were used to measure the pooled estimate of the effect size. In total, 1113 patients are represented from 15 selected studies, of whom 535 were treated by laparoscopic repair and 578 by open repair; 102 patients (19.1 per cent) underwent conversion to open repair. RESULTS: Statistically significant findings in favour of laparoscopic repair were less analgesic use, shorter hospital stay, less wound infection and lower mortality rate. Shorter operating time and less suture-site leakage were advantages of open repair. Three variables (hospital stay, operating time and analgesic use) were significantly heterogeneous in the papers analysed. CONCLUSION: Laparoscopic repair seems better than open repair for low-risk patients. However, limited knowledge about its benefits and risks compared with open repair suggests that the latter, more familiar, approach may be more appropriate in high-risk patients. Further studies are needed.

40 Perforated peptic ulcer open closure in the morbid obese

41 Perforated peptic ulcer free intraperitoneal air-differential diagnosis  Perforated peptic ulcer  Perforated diverticulitis  Perforated appendicitis  Perforated Crohn disease  Heimlich maneuver/Boerhaave syndrome  Through salpinx  Idiopathic

42 Perforated peptic ulcer LAMA-trial: open vs laparoscopic closure (Marietta Bertleff) Raw data

43 Perforated peptic ulcer exclusion of gastric carcinoma and helicobacter

44 Perforated peptic ulcer remaining questions  Best technique of closure?  Postoperative gastric aspiration?

45 Perforated peptic ulcer

46 Tissue glue

47 Perforated peptic ulcer Stamp method Bertleff M et al. Surg Endosc 2006 in press

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