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
Rudolph Valentino
James Joyce
Napoleon

5. Perforated peptic ulcer Acute abdomen (De Dombal n=30.000)
Appendicitis %
Cholecystolithiasis %
Occluded small intestine 4.1%
Gynecologic disorders %
Acute pancreatitis %
Urologic diagnosis %
Perforated peptic ulcer 2.5% (5-10 pro year)
Other diagnosis %
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

19. Perforated peptic ulcer Diagnosis

20. Perforated peptic ulcer

21. 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

27. 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
Distance ulcer>1cm
Lam et al. Surg Endosc 2005; 19:

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 Oct;29(10):
Related Articles, Links
              Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. Lunevicius R, Morkevicius M.
World J Surg 2005; 29: nd Department of Abdominal Surgery, Clinic of General and Plastic Surgery, Orthopaedics, and Traumatology, Vilnius University Emergency Hospital, Vilnius University, Siltnamiu Street 29, LT 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.
Br J Surg 2005; 92: 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 Perforated diverticulitis
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. Perforated peptic ulcer
Tissue glue

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