How Do They Fix a Perforated Duodenal Ulcer?

Ulcers can be treated with a surgical procedure called Omental patching.

Omental patching is a surgical procedure for treating perforated ulcers. It is also called a Graham patch after the surgeon who first performed this technique. This procedure uses a patch of the omentum to repair the injury because it is durable. 

Omental patching may be combined with other procedures such as the resection of the vagus nerve that stimulates acid production (vagotomy) to reduce acid production in the stomach or combined with other surgical procedures in case of very large ulcers. 

The medical treatment of Helicobacter pylori (H. pylori) infection and acidity is required. Diet and lifestyle modifications would have to be followed after the surgery to prevent the recurrence of ulcers. Sometimes, a perforated ulcer can seal itself by an adherent omentum. Hence, the patient may be managed with medical treatment instead of surgery.

An ulcer is discontinuation occurring on the external or internal surface of the body. Caused by trauma to the skin or a mucous membrane that does not heal, ulcers vary in width and depth. They can be painful and lead to severe complications. Ulcers can occur in the esophagus, stomach, and intestines (duodenum is the first part of the small intestine and connected to the stomach).

Ulcers occur when acid damages the lining of the digestive tract. The common causes of ulcers are bacteria Helicobacter pylori, improper diet habits, and medication that increases the stomach acid level (pain reliever group). If the ulcers are not treated appropriately, there is continuous damage to the lining of the digestive tract, and the depth of the ulcer increases, ultimately leading to complete perforation (a hole) and bleeding.

The omentum is a double-layered fatty tissue that covers and supports the intestines and organs in the abdomen. The omentum is made up of the greater omentum that is important storage for fat and the lesser omentum that connects the stomach and intestines to the liver.

Before the surgery

• The surgeon performs the complete physical assessment, and complete blood and radiological analyses before the surgery and takes informed consent from the patient.

During the surgery

• The surgery is performed under general anesthesia. 
• Different types of incisions may be used during the surgery, but the upper midline incision is the most popular, which provides good surgical exposure. 
• Once the bowel perforation is identified, sponges would be used to prevent further spillage of the stomach/intestinal contents at the perforation site. 
• Sutures are placed to prevent the leakage from bringing the margins closer. The greater omentum is then detached from the intestines and stomach. 
• Once the omentum is mobilized, it is then lengthened by dividing it according to the anatomic pattern of the vessels. 
• The omentum is then transferred to the site required to patch and strengthen the sutured area (stitches). 
• The applied tension to the sutures should be strong enough to stabilize the omentum in place but loose enough to preserve the omental blood supply. The surgical wound is then closed. A surgical drain may be inserted to drain the accumulated fluid and blood. 
• A tube placed through the skin of the abdomen into the midsection of the small intestine (feeding jejunostomy tube) may be inserted to provide nutrition postoperatively.

Laparoscopic approach

• A laparoscopic omental patch closure of the perforated duodenal ulcer has become increasingly common. It is less invasive, and the recovery rate is fast. 
• Multiple small incisions are made over the abdomen through which the laparoscope (a long, thin tube that has a tiny video camera and light on the end) and surgical instruments are inserted. A feeding jejunostomy tube may be inserted.

After the surgery

• Painkillers and antibiotics are administered after the surgery. 
• The patient may have to stay in the hospital for three-seven days after the surgery. 
• Feeding would be done through the jejunostomy feeding tube because oral feeding would be delayed until the patch heals. 
• Intravenous nutritional therapy may be administered as an alternative to a feeding tube.
• Attention to nutrition in the postoperative period is important to improve the health status of the patients and ensure adequate healing. 
• Pain, swelling, and bruising is normal in the postoperative period and usually resolves within two weeks. 
• Complete recovery can take four to six weeks.

The success rate of the surgery is high. Some complications that may be encountered are:

• Paralytic Ileus (paralysis of the small intestine)
• Bleeding
• Infection 
• Abscess (pus) formation 
• Gastric outlet obstruction
• Necrosis (tissue death)
• Post-operative leak