Anatomie si tehnici chirurgicale <strong>Jurnalul</strong> <strong>de</strong> <strong>Chirurgie</strong>, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]LAPAROSCOPIC REPAIR OF PERFORATED PEPTIC ULCERS. Luncă, N.S. Rome<strong>de</strong>a, C. MoroşanuEmergencies Surgery Clinic, Emergency Hospital IaşiUniversity of Medicine and Pharmacy „Gr.T. Popa” IaşiLAPAROSCOPIC REPAIR OF PERFORATED PEPTIC ULCER (Abstract): Since 1990 when Mouretreported the first laparoscopic sutureless repair for a perforated duo<strong>de</strong>nal ulcer and Nathanson the first successfullaparoscopic suture repair for perforated peptic ulcer, laparoscopic approach became a wi<strong>de</strong>spread procedure.Treatment for perforated ulcer can be performed laparoscopically in 85% of cases, making it possible to avoid amedian laparotomy which can lead to wound infection and late eventration. Laparoscopic approach is indicatedin any case of suspected gastroduo<strong>de</strong>nal perforation and seems to offer the same advantages as for the vastmajority of laparoscopic procedures. Nowadays laparoscopic repair of duo<strong>de</strong>nal perforation seems to be a usefulmethod for reducing hospital stay, complications and return to normal activity if carried on in proper manner.With better training in minimal access surgery and better ergonomics now available the time has arrived for it totake its place in the surgeon’s repertoire.KEY WORDS: LAPAROSCOPIC APPROACH, PERFORATED PEPTIC ULCERCorrespon<strong>de</strong>nce to: Sorin Luncă MD, PhD, Assoc. Prof. of Surgery, Emergencies Surgery Clinic, EmergencyHospital Iaşi, Gen. Berthlot Street, no. 2, Iaşi, România; e-mail: sdlunca@yahoo.com *INTRODUCTIONDuo<strong>de</strong>nal perforation is a common complication of duo<strong>de</strong>nal ulcer. Perforatedduo<strong>de</strong>nal ulcer is mainly a disease of young men but because of increasing smoking inwomen and use of NSAID in all the age group, nowadays it is common in all adultpopulation. Up to eighty percent of perforated duo<strong>de</strong>nal ulcers are Helicobacter pyloripositive.Treatment for perforated ulcer ranges from conservative treatment (Taylor’s approach)to radical surgery (vagotomy, gastrectomy). However, with the use of powerful acidsuppressingmedication and the eradication of Helicobacter pylori, the need for radicalsurgery in emergencies has sharply <strong>de</strong>clined. The surgical technique most often used isclosure of the perforation combined with extensive peritoneal lavage. Repair of duo<strong>de</strong>nalperforation by Graham patch plication (as was <strong>de</strong>scribed in 1937) represents an excellentalternative approach.Perforated duo<strong>de</strong>nal ulcer is a surgical emergency. In 1990 Mouret et al. [1] reportedthe first laparoscopic sutureless fibrin glue omental patch for perforated duo<strong>de</strong>nal ulcer repair.The first successful laparoscopic suture repair for perforated peptic ulcer was <strong>de</strong>scribed byNathanson et al. also in 1990 [2,3]. Soon after that, the laparoscopic approach became awi<strong>de</strong>spread procedure.Laparoscopic repair of duo<strong>de</strong>nal perforation is a useful method for reducing hospitalstay, complications and return to normal activity.Treatment for perforated ulcer can be performed laparoscopically in 85% of cases,making it possible to avoid a median laparotomy which can lead to wound infection and lateincisional hernia. With better training in minimal access surgery now available, the time hasarrived for it to take its place in the surgeon’s repertoire.* received date: 8.02.2007accepted date: 7.03.2007171
Anatomie si tehnici chirurgicale <strong>Jurnalul</strong> <strong>de</strong> <strong>Chirurgie</strong>, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]In case of sepsis, however, the creation of a pneumoperitoneum involves two risks:- hypercapnia: carbon dioxi<strong>de</strong> absorption is increased by peritoneal hyperemia;- - bacteremia: either via translocation or direct bacterial passage through the lymphatics ofthe diaphragm and the thoracic duct.Some basic principles must be followed. They inclu<strong>de</strong> intravenous antibiotic therapybefore insufflation, intraabdominal pressure between 8 and 12mmHg and initially performingperitoneal lavage.Laparoscopic approach seems to offer in case of perforated peptic ulcer the sameadvantages as for the vast majority of laparoscopic procedures:- cosmetically better outcome;- less tissue dissection and disruption of tissue planes;- less pain postoperatively;- low intra-operatively and postoperative complications;- early return to work.Laparoscopic approach is indicated in any case of suspected gastroduo<strong>de</strong>nalperforation.Contraindications for laparoscopic approach are:- high risk patient -ASA class IV;- massive ileus;- advanced purulent peritonitis;Fig. 1 Patient, team and equipment position.An-anaesthetic unit; L-laparoscopic unit;C- surgeon; As- assistant; T-operative table- surgeon with limited laparoscopic experience;- suspected perforated gastric cancer.Fig. 2 Trocars positionsSURGICAL TECHIQUEPatient positionAt the beginning of the procedure the patient is placed in supine position with legsstraight and spread out. The patient position is changed several times during procedure: insteep anti-Tren<strong>de</strong>lenburg position during suture and in lateral <strong>de</strong>cubitus and Tren<strong>de</strong>lenburgposition during peritoneal lavage.172
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