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    Laparoscopic Management of Duodenal Perforation

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    mokhtar

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    Laparoscopic Management of Duodenal Perforation

    Uploaded by

    mokhtar
    5 views41 pages

    Original Title

    Laparoscopic Management of Duodenal perforation

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    5 views41 pages

    Laparoscopic Management of Duodenal Perforation

    Uploaded by

    mokhtar

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 41

    Laparoscopic Repair of

    Duodenal Perforation

    R. K. Mishra

    World Laparoscopy Hospital


    Perforated peptic ulcer
    famous fatalities

    Rudolph Valentino

    World Laparoscopy Hospital


    James Joyce
    Napoleon
    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%
    World Laparoscopy Hospital
    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)
    World Laparoscopy Hospital
    Perforated peptic ulcer
    morphology related to location

    juxta-pyloric ulcer:
    small, healthy border

    gastric ulcer at lesser curvature:


    large, fibrotic edematous border
    (ulcus callosum)
    World Laparoscopy Hospital
    Perforated peptic ulcer
    perforated gastric carcinoma

    World Laparoscopy Hospital


    Perforated peptic ulcer
    sealing off by left liver half

    World Laparoscopy Hospital


    Perforated peptic ulcer
    sealing off by segment IV

    World Laparoscopy Hospital


    Perforated peptic ulcer
    sealing off by liver lobe

    World Laparoscopy Hospital


    Perforated peptic ulcer
    fibrinous peritonitis+parahepatic collection

    World Laparoscopy Hospital


    Perforated peptic ulcer
    ulcer visible after lifting left liver lobe

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Bacteriology

     <48h in 50%: sterile peritonitis; in


    other 50%: grampositive peritonitis
     >48h: infected peritonitis, most
    often grampositive initially, later
    gramnegative

    World Laparoscopy Hospital


    Perforated peptic ulcer
    cause of death: peritonitis

    Pre-antibiotics-mortality: 75%

    World Laparoscopy Hospital


    Perforated peptic ulcer
    subphrenic abcess

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Boey prognostic parameters

     Age
     Duration of symptoms
     Shock
     ASA III-IV
     Diameter of ulcer

    World Laparoscopy Hospital


    ASA
     ASA I - A normal healthy patient. (ASA = American
    Society of Anesthesiologists)
     ASA II - A patient with mild systemic disease.
     ASA III - A patient with severe systemic disease.
     ASA IV - A patient with severe systemic disease that is a
    constant threat to life.
     ASA V - A moribund patient who is not expected to
    survive without the operation.
     ASA VI - A declared brain-dead patient whose organs are
    being removed for donor purposes.
     E - Emergency operation of any variety (used to modify
    one of the above classifications, i.e., ASA III-E).

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Diagnosis

    World Laparoscopy Hospital


    Endoscopy

    World Laparoscopy Hospital


    Endoscopy

    World Laparoscopy Hospital


    World Laparoscopy Hospital
    CT Scan

    World Laparoscopy Hospital


    Perforated peptic ulcer

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Diagnosis

     1) X-thorax/abdomen in upright
    position
     If negative:
     2) CT with oral contrast

    World Laparoscopy Hospital


    Perforated peptic ulcer
    duration of postoperative pneumoperitoneum

     X: <6 days: 90%


     CT: <6 days: 50%; <18 days: 100%

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Operative therapy (history)

     1892 resection: Heusner


     1894 oversewe: Dean
     1937 omental patch: Graham
     1990 laparoscopy: Mouret

    (1947 Taylor: conservative)


    World Laparoscopy Hospital
    Perforated peptic ulcer
    Operative therapy (closure+lavage)

     Only after resuscitation


     Closure+lavage
     Postoperative gastric aspiration
     Acid suppression (PPI’ s)
     Antibiotics

    World Laparoscopy Hospital


    Perforated peptic ulcer
    laparoscopic closure

    World Laparoscopy Hospital


    World Laparoscopy Hospital
    Perforated peptic ulcer
    laparoscopic closure

    World Laparoscopy Hospital


    Perforated peptic ulcer
    (stapler-fixation of omentum)

    World Laparoscopy Hospital


    Perforated peptic ulcer
    rendez vous omental patch

    World Laparoscopy Hospital


    Graham 1937: omental patch plication
    (without primary closure of ulcer)

    World Laparoscopy Hospital


    Perforated peptic ulcer
    3 stitch-Graham omental patch
    Distance ulcer>1cm

    World Laparoscopy Hospital Lam et al. Surg Endosc 2005; 19: 1627-30
    Perforated peptic ulcer
    3 stitch-Graham omental patch

    World Laparoscopy Hospital


    Perforated peptic ulcer

    Flat tire test

    World Laparoscopy Hospital


    Perforated peptic ulcer
    operative therapy: abdominal complications

     Re-leakage: 10%
     Intra-abdominal abscess: 3%

    World Laparoscopy Hospital


    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

    World Laparoscopy Hospital


    Perforated peptic ulcer

    Tissue glue

    World Laparoscopy Hospital


    Perforated peptic ulcer
    Stamp method

    Bertleff M et al. Surg Endosc 2006 in press


    World Laparoscopy Hospital
    Laparoscopic repair of Duodenal
    Perforation

    World Laparoscopy Hospital


    Thanks

    Batch June 2007

    World Laparoscopy Hospital

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