CLOSURE OF PERFORATION

INDICATIONS
Perforation of an ulcer of the stomach or duodenum is a surgical emergency; however, before
performing the operation, sufficient time should be allowed for the patient to recover from the
initial shock (rarely severe or prolonged) and for the restoration of the fluid balance. The
choice for closure of the perforation versus a definitive ulcer procedure depends upon the
overall assessment of risk factors by the surgeon.
PREOPERATIVE PREPARATION
A narcotic is used to control pain only after the diagnosis is established. The intravenous
administration of saline, glucose, and colloids may be necessary, depending upon the
patient's general condition and the length of time that has elapsed since perforation. The
parenteral administration of antibiotics and the institution of constant gastric suction are
routine.
ANESTHESIA
General endotracheal anesthesia combined with muscle relaxants is preferred. In the poorrisk patient or patients with severe respiratory infection, local infiltration anesthesia is
substituted.
POSITION
The patient is placed in a comfortable supine position with the feet slightly lower than the
head to assist in bringing the field below the costal margin and to keep gastric leakage away
from the subphrenic area.
OPERATIVE PREPARATION
The skin is prepared in the usual manner.
INCISION AND EXPOSURE
Since the majority of perforations occur in the anterior superior surface of the first portion of
the duodenum, a small, high, right rectus midline or right paramedian incision is made. A

culture of the peritoneal fluid is taken, and as much exudate as possible is removed by
suction. The liver is held upward with retractors, exposing the most frequent sites of
perforation. The site may be walled off with omentum if the perforation has been present
several hours; therefore, care is exercised in approaching the perforation to avoid
unnecessary soiling.
DETAILS OF PROCEDURE
The easiest method of closure consists of placing three sutures of fine silk through the
submucosal layer on one side and extending through the region of the ulcer and out a
corresponding distance on the other side of the ulcer (Figure 1). Starting at the top of the
ulcer, the sutures are tied very gently to prevent laceration of the friable tissues. The long
ends are retained (Figure 2). The closure is reinforced with omentum by separating the long
ends of the three previously tied sutures and placing a small portion of omentum along the
suture line. The ends of these sutures are loosely tied, anchoring the omentum over the site
of the ulcer (Figure 3).
The tissue may be so indurated that the ulcer cannot be closed successfully, making it
necessary to seal the perforation by anchoring omentum directly over the ulcer.
In the presence of a perforated gastric ulcer, a small biopsy of the margin of the perforation is
taken because of the possibility of malignancy (Figures 4 and 5). The omentum may be
anchored over the suture line (Figure 6). Closure of a gastric ulcer may be reinforced with a
layer of interrupted silk serosal sutures, since there is little danger of obstruction.
In the presence of perforation of an obvious carcinoma, it is usually safer to close the
perforation, to be followed upon recovery by resection. If the patient's general condition is
good and the perforation has lasted only a few hours, a gastric resection may be justified.
Vagotomy and pyloroplasty or antrectomy for an early perforated duodenal ulcer in a goodrisk patient is preferred by some surgeons.
CLOSURE
All exudate and fluid are removed by suction. Repeated irrigation of the peritoneal cavity with
saline should be considered when there is gross contamination by food particles. The wound
is closed without drainage. A temporary Stamm gastrostomy (see Gastrostomy) should be
considered since prolonged obstruction of the pylorus may occur.
POSTOPERATIVE CARE
The patient, when conscious, is placed in Fowler's position. Constant gastric suction is
continued for several days until there is reasonable assurance that the pylorus is not
occluded by edema. The tube is removed when the stomach is emptying satisfactorily. The
fluid balance is maintained by intravenous infusions. Antibiotics are continued. Medications
that lessen gastric acid secretion may be given intravenously. After three to four days, the
patient is started on a strict ulcer diet regimen. Simple closure of the perforation has not cured
the patient of his or her ulcer nor of his or her tendency to form another. It must be
remembered that a subphrenic or a pelvic abscess may complicate the postoperative period.
Serum gastrin levels are determined and intensive medical treatment is continued.
SUBPHRENIC ABSCESS
INDICATIONS
The most common origins of a subphrenic abscess are perforation of a peptic ulcer,
perforation of the appendix, or acute infection of the gallbladder. It is to be suspected in an
unsatisfactory recovery from any of these conditions. Intensive antibiotic therapy may mask
the systemic reaction to the infection. Chest x-ray films may show a pleural effusion and
ultrasound or CT scans should be diagnostic. Additionally, the CT scan may guide a fine
needle aspiration for culture or the placement of a catheter for drainage if the pus is thin and
the cavity is unilocular.

PREOPERATIVE PREPARATION
The clinical data combined with roentgenologic studies usually indicate the location of the
abscess. The location and extent of the abscess often can be defined by computed
tomography (CT), which may also be used to guide needle aspiration or catheter drainage.
Subphrenic abscesses occur much more frequently on the right side. Antibiotics, blood
transfusions, and intravenous fluids are usually necessary because of the prolonged sepsis.
ANESTHESIA
Local anesthesia by direct infiltration of the site of the incision is preferable for the poor-risk
patient. Spinal or inhalation anesthesia also may be used, depending upon the patient's
general condition.
POSITION
For an anterior abscess the patient is placed supine with the head of the table elevated. For a
posterior abscess the patient is placed on his side with the arm on his affected side pulled
forward.
OPERATIVE PREPARATION
The skin is prepared in the usual manner.
Anterior Abscess
INCISION AND EXPOSURE
The incision is placed one fingerbreadth below the costal margin and extended from the
midrectus region laterally (Figure 7). The free peritoneal cavity is not opened.
DETAILS OF PROCEDURE
The surgeon inserts the index finger upward between the peritoneum and diaphragm until the
abscess cavity is encountered; extraperitoneal drainage is thus established (Figure 8).
Posterior Abscess
INCISION AND EXPOSURE
It is desirable to drain the subphrenic abscess by the extraperitoneal route without rib
resection whenever possible. On occasion it may be desirable to approach the abscess
through the bed of the twelfth rib (Figure 9, Incision A). The entire twelfth rib is resected. The
erector spinae are retracted toward the midline, and a deep transverse incision is made at
right angles to the vertebrae across the periosteal bed of the resected rib, opposite the
transverse process of the first lumbar vertebra (Figure 9, Incision B).
DETAILS OF PROCEDURE
The location of the abscess cavity is approached by the index finger of the surgeon, who
separates the peritoneum from the undersurface of the diaphragm, thus ensuring dependent
drainage without contamination of the peritoneal cavities (Figure 10). Once pus has been
obtained, the abscess cavity can be entered and thoroughly evacuated, and rubber tissue
drains or mushroom catheters can be inserted. Several cultures are taken routinely, and the
sensitivity of the offending organism is determined. Some organisms, such as
Staphylococcus, require isolating the patient to prevent spread of the organism to others.
If the abscess cavity is difficult to palpate, aspiration exploration with a 20-gauge needle on a
10-mL syringe is usually successful. Do not aspirate the cavity empty, as it will become even
more difficult to palpate and find the correct pathway. Last, if the abscess cavity has not been
adequately drained with a small catheter placed under CT or ultrasound guidance, that
catheter should be left in place to guide the surgeon.

CLOSURE
Drains are inserted into the abscess cavity in numbers indicated by the size of the abscess.
There is no further closure.
POSTOPERATIVE CARE
The abscess cavity is carefully irrigated with normal saline each day and the capacity of the
cavity measured from time to time. The external opening is maintained and the drains or
tubes are removed sequentially as the cavity is obliterated. Vigorous pulmonary and
nutritional support is given and antibiotics are continued until sepsis is over.
If the chest is entered, closure of the opening with placement of a temporary chest tube is
usually necessary.