Duodenal Ulcer Perforation
DUODENAL ULCER PERFORATION
Young, anxious, male, patient, professional job, smoker, alcoholic
History of recurrent pain in upper abdomen (peptic ulcer symptoms in past)
History of sudden give way sensation in abdomen followed by excruciating pain in epigastrium & right hypochondrium migrating to the right iliac fossa & back (+/-)
Fever, vomiting - nonbilious contents (due to pylorospasm)
Giddiness, sweating and profound weakness
Febrile, tachycardia, tachypnea, low volume pulse, cold clammy extremities
Guarding, rigidity - epigastric & right hypochondrial or generalized
Obliteration of liver dullness
As stages of peritonitis proceeds it leads to paralytic ileus and movement of bowel decreases
Hippocratic fades in the late stages
Porphyria, tabes Dorsalis
Orders to be given till diagnosis is reached
Nil by mouth
Central line, Ryle's tube, Foley's catheter
Ryle's tube aspiration — one hourly and continuous
TPR / BP / Abdominal girth - One hourly
Input! output charting
Antibiotics - Injection Cefotaxim and Metronidazole
Injection pethidine (after diagnosis reached)
Investigations to confirm diagnosis
X-ray chest with both the domes of diaphragm/abdomen -
In standing position, if can not stand, in left lateral position
Diagnostic - Gas under diaphragm (minimum 1 cc required) in standing position, free gas accumulates over liver in left lateral position
If no gas seen, repeat X-ray after injection of air through Ryle's tube (400 ml), Disadvantage - Contents of stomach may be pushed out leading to aggravation of the peritonitis.
Abdominal paracentesis -
Diagnostic - Positive in right upper & negative in right lower
Positive in all 4 Quadrants - ileal perforation
Examine fluid for
Infection / bilious / fecal contamination
If acidic - gastric
Send for smear, culture antibiotic sensitivity
Hb, CBC, ESR
BUN, serum creatinine, electrolytes
If diagnosis is confirmed
Nil by mouth
Informed consent for surgery
Ryle's tube aspiration hourly & continuous
TPR, BP, abdominal girth 1/2 hourly
Input/Output charting, maintain CVP at 4-6 cm atleast
IV fluids -
For correction of shock and electrolyte imbalance
To ensure good kidney function (Urine output 0.5-1 ml/kg/hour is satisfactory)
Hydrate with Ringer's lactate + Normal saline because large amounts of chlorides lost in Gastro-intestinal fluids. Colloid may be given in case of severe hypovolemia
Blood sent for grouping & cross matching
Head high position [Because pelvic abscess easier to treat]
Shave nipple to knee
Injection Atropine 0.6 mg
Injection Pethidine (if not given previously)
Antibiotics - Cephalosporins, Aminoglycosides, and Metronidazole
Once patient has been stabilized (Pulse - 100-120/ min, regular, BP - 110/70 mm of Hg., Urine output - 50 ml/hour, CVP 4-6 cm) patient taken to operation theatre
Anaesthesia - General
Parts prepared, painted & draped.
If site of perforation confirmed as Duodenal Ulcer a right upper Paramedian incision 1-1/2 inches right of midline, 1 inch below 9th costal cartilage down for adequate length.
If site not known right mid midline incision
Lower limit of incision - 2 fingers above umbilicus,
Upper limit - 2 fingers below subcostal margin
Layers cut -
Anterior rectus sheath opened up in the line of incision edges are lifted up with Allis/ Artery
Control bleeding by hemostat & rectus muscle is dissected away laterally exposing posterior rectus sheath and transversalis fascia. These are picked up with 2 hemostats & incised along the line of skin incision.
Expose the Peritoneum
Lift up peritoneum & nick the peritoneum by scalpel by keeping the blade horizontal by 3 forceps technique. Open at an acute angle.
Incision extended & peritoneum opened with Stelles taking care to protect the underlying structures with fingers.
The gas in the peritoneal cavity escapes with a hiss
Aspirate the peritoneal fluids & sent for smear, culture anti-biotic sensitivity.
Looking for perforation a complete exploration is done starting from the stomach trace it distally to the pyloroduodenal junction. Stomach is identified as a hollow muscular organ with the presence of Ryle's tube, with lesser and greater curves and omentum, Stomach is delivered out of incision and traced down to the duodenum.
Duodenal Ulcer perforation
Usually on the anterior wall of 1st part of Duodenum, Note acute or chronic
The assistant retracts the stomach to left, while the 2' assistant retracts the liver with Dever's retractor, the 1st part of Duodenum is thus exposed. A note is made of posterior wall perforation, if any.
If perforation cannot be obviously seen as a hole with exudation of bilious fluid then -
Look on 1st part of duodenum by identifying above structures - 70 % perforation there.
The visualization is facilitated by holding the Greater curvature of stomach & pulling it with the Ryle's tube downwards & outwards towards
If first part of duodenum does not show perforation on its anterior and posterior aspects, trace the second and third parts of duodenum. If no perforation found, rule out perforation on anterior surface and curvatures of stomach. If still no perforation can be visualized, open up the gastrocolic omentum and enter the lesser sac to inspect the posterior surface of stomach, second and third parts of duodenum in details for perforation.
Once perforation has been identified
An acute perforation is found on the anterior wall of first part of Duodenum with no duodenal scarring. (Implies that the perforation is acute)
Retract liver with Dever's retractor. Retract colon and small bowel inferiorly
Hold stomach in wet warm mop & pull anteriorly to left to isolate first part of duodenum
Gradually dissect out omentum from site of adhesion. Suck out the fluid from perforation & around.
Note size of perforation -
Acute - Pin point
Chronic - Fibrosing ring around perforation
If the fibrosing ring is large then scrapping may be done to freshen the edges
Note - Posterior perforation is more dangerous because of pancreaticoduodenal artery in relation
Assistant keeps area of suture clean by sucking near perforation - Now take 3 medium sized sutures on round bodied needle with non absorbable material (6-0 linen / 3-0 mersilk parafinised). Direction must be parallel to the direction of bowel (to prevent stenosis)
Sutures must be through and through (all 3 layers). Check after each suture that posterior wall is not taken in bits of needle.
1st one - goes through center of perforation (across the ulcer).
2nd and 3rd one - by side of perforation (corners).
(A patch of omentum is placed over the Ulcer site and the sutures are tied over the same- live °mental pedicle graft. This technique is called Roscoe Graham's Technique. If a nonvascular omental twig kept, it is called Cullen Jone's technique)
The ends of the sutures are then cut short.
Peripheral ones are tied first and then the middle one in order to relieve the central. stitch tension.
Take a big stitch to include a large part of the normal tissue because -
Induration around ulcer, edema and therefore sutures do not hold well.
Actual perforation, may be quite big but may be masked by pus flakes and therefore go well beyond the perforation on either side while taking sutures.
Also upper and lower stitches - the ends are kept long. Middle - normal.
Inspect all the rest of bowel from duodenojejunal flexure to ileocecal junction for any other lesion - TB, worms, Meckel's, appendix.
Give a thorough lavage in peritoneal cavity
Over liver and spleen
In subdiaphragmatic pouch
In right iliac fossa, right para colic gutter
In left iliac fossa, left .para colic gutter
Lavage can be given with
Warm normal saline with or with out antiseptic (Povidone iodine), in large amounts to dilute the infecting organisms.
Mop dry the peritoneal cavity
Leave an intraperitoneal drain (32 F tube drain) in hepatorenal pouch of Sir Rutherford Morrisson. It is brought out through the flank, anterior to midaxillary line, at a point mid way between iliac crest and subcostal margin. Another drain is usually left in the pelvis and brought out from the similar point on the left side.
Usually drain required if
Evidence of severe bacterial peritonitis and flakes of pus.
Large size ulcer with chances of leak.
Peritoneum with 2/0 chromic catgut with curved round bodied needle, continuous interlocking stitches.
Posterior rectus sheath with 2/ 0 - 3/ 0 chromic catgut or vicryl with interrupted sutures.
Reposition of rectus muscle.
Close anterior rectus sheath with number 1 ethilon
Subcutaneous tissue with plain catgut by simple interrupted stitches
Skin and with interrupted sutures with 2-0 or 3-0 ethilon
If ulcer is too big with friable duodenum the stitches cut through.
Block it with omental patch and fix it with 2 or 3 stitches without suturing ulcer.
Thai's patch (jejuna' serosal patch) can be applied over the ulcer
Create a formal duodenosotomy - create a fistula and introduce a tube.
Lemberes sutures are generally not taken as it cicatrizes the duodenal lumen.
In cases of large duodenal ulcers with severe contamination, a decompressing gastrostomy and a feeding jejunostomy is preferred. Bile drained through gastrostomy is fed into jejunostomy along with feeds. A gastroduodenogam is done after 15 days to confirm healing. If no leak is found then gastrostomy is removed followed by removal of jejunostomy is patient tolerates full feeds.
Role of definitive repair
Note - Classification of Duodenal ulcer at laparotomy
No contamination - little bile.
Severe or heavy contamination
Prerequisites for definitive surgery
A trained surgeon and a good team
A chronic duodenal ulcer
On table - scarring and induration or post bulbar stenosis which will require definitive surgery at later date
Perforation has occurred within the last 6 hours.
There should be minimum contamination
Age more than 30 years
General condition of the patient should be good
Ulcer suture with-truncal or highly selective vagotomy with drainage procedure (pyloroplasty or gastrojejunostomy) Pyloroplasty — if no duodenal scarring
Gastrojejunostomy — if duodenal scarring / post bulbar stenosis / dilated stomach
If contamination heavy
Acute perforation (no past history of peptic ulcer disease)
Lack of expertise
Post operative orders
TPR, Input-output chart, abdominal girth 1 hourly
Ryle's tube aspiration 1 hourly and continuous
Chest physiotherapy and tincture benzoin inhalation QDS. Vigorous chest physiotherapy is a must to avoid post operative chest problems
Injection Ranitidine (50 mg) 8 hourly
Analgesics (avoid NSAIDs)
When Ryle's tube aspiration becomes less
Then patient can be started on oral sips
Once the patient tolerates this, give liquid diet and then give full diet
Patient should sit up by 48 hours and should be walking by 72 hours.
Drainage tube removed when patient tolerates feed (usually 5th day)
In case of suspected leaks, dilute methylene blue can be passed via Ryle's tube and watched for drainage into the drains
In case of frank leaks, decompress the stomach, keep NBM and conserve with strict drain output monitoring. If this fails, re-exploration is required.
Partial gastrectomy followed by Bilroth's I/II anastomosis (Bilroth's I for antral perforation, Bilroth's II for body perforation
Orders on discharge
Antacids (Not required if a definitive surgery is done)
Regular follow up
Endoscopy at the end of 3 months and regularly thereafter to note the progress of the ulcer. Usually patients are well controlled medically, but some may require surgery later.
On the table
Damage to liver or accidental injury to viscera like stomach, duodenum, common bile duct
Sutures of posterior wall of duodenum
Friable ulcer - cannot take bite as it keeps on breaking
Off the table
Paraduodenal, subhepatic, paracolic, subphrenic, pelvic abscess
Duodenal stenosis and obstruction
Aim is to conserve till patient becomes fit for surgery
High risk patient, with unstable hemodynamic.s Surgery contra-Indicated / facilities not available.
IV fluids, colloids if required to maintain BP, urine output and CVP
Pass Ryle's tube and drain contents one hourly and contintious
Urine output charting and monitoring
TPR/BP/Abdominal girth hourly
Look for abdominal guarding, rigidity and tenderness
IV Ranitidine (50mg) 8 hourly
Drains may be put under local anesthesia in pelvis and Morrison's pouch
Methylene blue test through Ryle's tube followed by oral liquid sips, if the test does not detect any leak. If the patient tolerates liquid sips then liquid diet is started, followed by solid diet - followed by full diet.
Large perforation -
Duodenal ulcer perforation with suturing (more than 3 sutures may be required)
Roscoe - Graham's surgery
Thai's patch - bringing up a loop of jejunum and taking seromuscular stitched to the perforation so that the serosa of the jejunum forms the wall of duodenum.
Perforation with gastric outlet obstruction
Suturing the perforation
Vagotomy pyloroplasty including the duodenal ulcer perforation with
Perforation with posterior bleeding ulcer
(Kissing ulcer with hemorrhage)
Correct blood loss
Stop the bleeding and correct the perforation
Blood vessel is identified and under run with figure of 8 stitch using No 2-0 vicryl, taking care not to include the common bile duct