Laparoscopic Repair of Perforated Peptic Ulcers: The Sutured Omental Patch and Focused Sequential Lavage Technique Sze Li Siow, MBBS, MRCS, MS, and Hans Alexander Mahendran, MD, MS Abstract: We propose a standardized technique of repair and lav- age with the outcomes of 50 consecutive patients treated at our institution. The perforation was closed primarily and reinforced with omental patch. It was then followed by peritoneal lavage in a focused sequential manner that involved quadrant to quadrant lavage with tilting of operating table and changing of position between the surgeon and the camera surgeon. None of our patients had postoperative intra-abdominal complications, but unfortunately 1 patient succumbed to respiratory complications. Respiratory com- plications was the most common postoperative complication in our series (9 patients), whereas 2 patients had ileus. There were no leaks or reoperations in our series. Laparoscopic repair and sutured omento- plasty, followed by focused sequential lavage in a systematic manner, if performed diligently, will yield good outcomes. Key Words: laparoscopy, perforated ulcer, omental patch, focused sequential lavage (Surg Laparosc Endosc Percutan Tech 2014;24:134–139) S ince its initial description by Mouret et al in 1990, 1 the laparoscopic approach is slowly gaining acceptance in the treatment of perforated peptic ulcers (PPU). The out- comes vary according to the laparoscopic experience of the surgical team. The 2 key steps in laparoscopic repair of PPU is the repair of perforation and peritoneal lavage. The former is straightforward with emphasis on the laparo- scopic suturing techniques and reinforcement with pedicled omentoplasty. The latter is time consuming and tedious but more important, as it determines the rate of postoperative complications. This paper describes the systematic approach to laparoscopic PPU repair we have adopted and the sequential steps in peritoneal lavage. PATIENTS AND METHODS Patients Between December 2009 and June 2012, a total of 50 patients (46 men and 4 women) were diagnosed with PPU underwent emergency laparoscopic repair at Sarawak General Hospital. Laparoscopic repair of PPUs is the procedure of choice for patients with low Boey risk scores. Since the first description by Boey et al, 2 the risk strat- ification system has been shown to be useful in predicting morbidity and mortality in many studies. 3–5 Laparoscopic repair is preferentially performed for patients with Boey scores 0 or 1. However, laparoscopic repair in patients with high Boey scores of 2 or more are attempted at our insti- tution, if they can be haemodynamically stabilized preoperatively. Surgical Technique The patient is placed in Lloyd-Davies position under general anesthesia. The surgeon stands between the patient’s legs with the camera surgeon on the right of the patient. The additional assistant or scrub nurse stands on the left side of the patient with the laparoscopic trolley. The monitor is placed on the left top end of the patient (Fig. 1). A 3-port technique is usually used using a subumbilical 10-mm port for the 30-degree telescope. A right-hand working port using either an 11- or 12-mm Xcel port is inserted along the patient’s left midclavicular line. The left- hand working port using a 5-mm trocar is positioned along the patient’s right midclavicular line. These 3 ports are usually in line with each other horizontally. An accessory fourth 5-mm trocar can be utilized in the event, there is a need for retraction of a bulky left liver lobe. Alternatively, a percutaneously inserted suture can be used to suspend the falciform ligament and elevate the liver. Identification of the perforation site and repair of the perforation is the first priority before attempting proper peritoneal lavage. Otherwise, effluent from the perforation will continuously leak making attempts at lavage futile. Minimal lavage and suction is often necessary to aid in identification of the site of perforation if it is obscured by purulent fluid and thick slough. Suturing Technique Interrupted, intracorporeal suturing and knotting is preferred as extracorporeal knotting wastes a lot of sutures. The needle entry point is usually >1 cm away from the perforation as to avoid tearing of suture through the friable ulcer edge during approximation. Interrupted sutures, usually 2 or 3 stitches, are placed in a transverse manner overlying the perforation. Intracorporeal knotting is per- formed using a reef-slip knot conversion technique. This technique is useful when the edges of the ulcer are difficult to approximate as in the case of chronic callous ulcers. If the knot appears loose despite this maneuver, a hem-o-lock (Weck; Teleflex Medical, Ireland) could be applied prox- imally to secure it. We routinely perform pedicled omentoplasty. In our experience, pedicled omentoplasty is particularly useful, especially when dealing with chronic callous ulcer. In such cases, the perforation sometimes cannot be completely approximated or the ulcer edge may be friable with the sutures cutting through the edges. The perforation is first approximated using 2/0 polyglactin 910 (Fig. 2). A single stitch is inserted without tying the knot and the omentum is Received for publication November 26, 2012; accepted February 1, 2013. From the Department of Surgery, Sarawak General Hospital, Jalan Hospital, Kuching, Sarawak, Malaysia. The authors declare no conflicts of interest. Reprints: Sze Li Siow, MBBS, MRCS, MS, Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93584 Kuching, Sarawak, Malaysia (e-mail: szeli18@yahoo.com). Copyright r 2014 by Lippincott Williams & Wilkins ORIGINAL ARTICLE 134 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech  Volume 24, Number 2, April 2014