Laparoscopic repair of perforated peptic ulcer
Sir
We read with interest the Surgical Workshop by Mr Sunderland and colleagues on laparoscopic repair of perforated peptic ulcer (Br J Surg 1992; 79: 785). Our team performed six such repairs between March and October 1992. All patients were men, with a mean age of 35 (range 20-60) years. The duration from perforation to laparoscopy ranged from 8 to 12 h. Patients were selected according to accepted criteria for simple repair in perforated ulcers'. The size of perforation ranged from 3 to 6mm. Peritoneal soiling was assessed as moderate in all cases. The perforation was repaired first by intracorporeal suture of the hole closed using 2/0 catgut tied in a surgeon's knot. Thereafter, a piece of omentum was placed over the site and attached to the sutures by tying or with Endo-Clips (Ethicon, Somerville, New Jersey, USA). In the first four cases four ports were needed (two of 11 mm, two of 5 mm) to complete the procedure. In subsequent cases, only three ports were used (two of 11 mm, one of 5 mm), as the omentum was held in place by putting the patient in the Trendelenburg position. The abdomen was washed thoroughly with 4-6 litres saline. The mean operating time was 80 (range 65-90) min. There were no postoperative complications. Bowel sounds commenced on the first or second day after operation and all patients resumed diet by the fourth. The average hospital stay was 5 (range 4-7) days. Follow-up ranged from 2 to 8 months. To date all patients have been asymptomatic except for one who complained of dyspepsia 2 months after operation; endoscopy did not reveal a recurrent ulcer.
The early experience of laparoscopic repair of perforated peptic ulcer is encouraging. The greatest benefit of laparoscopic repair will be seen in elderly patients, in whom problems of diagnosis coexist with appreciable morbidity and mortality'. More data are needed to evaluate this new approach, Furthermore, some patients will need definitive operation for ulcer diathesis'. Although the early results of laparoscopic vagotomy have been good3, laparoscopic repair of a perforated ulcer combined with laparoscopic vagotomy in an emergency setting has not yet been performed, We are presently planning a controlled trial, which would complement our minimally invasive approach to peptic ulcer disease (Table ).