and 78 years, presented with an acute abdomen and a provisional diagnosis of a perforated ulcer. After initial resuscitation they were all laparoscoped within 12 ...
Ann R Coll Surg Engl 1996; 78: 390-391
SURGICAL TECHNIQUE
Laparoscopic repair of perforated duodenal ulcers with a falciform ligament patch W S Munro
FRACS Surgical Registrar
D Menzies
MS FRCS Consultant Surgeon
F Bajwa
FRCS Surgical Registrar
Colchester General Hospital, Colchester, Essex
Key words: Falciform ligament; Duodenal ulcer; Laparoscopy
Six patients are reported who presented with perforated duodenal ulcers. These were repaired laparoscopically by suturing the falciform ligament over the perforated ulcer. There were no complications and patients were discharged between 3 and 5 days after surgery. This technique is simpler to perform than a laparoscopic omental patch repair.
Laparoscopic treatment of perforated duodenal ulcers is becoming an established treatment (1-3). In our own practice, laparoscopic repair is our preferred means of management. After some experience of omental patch repairs we modified our technique to utilise the falciform ligament as the closing patch.
closed primarily with interrupted 2/0 Vicrylg sutures. The falciform ligament was then sutured down over the ulcer site with three further interrupted sutures. The four remaining patients did not have a primary closure of the ulcer but simply had the falciform ligament sutured over the ulcer with interrupted 2/0 Vicryl. In each case the falciform ligament patch covered the ulcer completely without tension. No mobilisation of the falciform ligament was necessary in any case. The patients' postoperative recovery was unremarkable. All were kept nil by mouth until the following day, then allowed fluids as tolerated. Discharge was between day 3 and day 5.
Discussion Materials and methods
In the course of laparotomy for perforated duodenal ulcer, of the first manoeuvres is often to retract or divide the falciform ligament. For this reason a close relationship to the first part of the duodenum is not readily appreciated. At laparoscopy this association is easily seen (Fig. 1). Use of the falciform ligament has been described in open surgery (4). This technique is not widely used. We believe it has advantages in laparoscopic surgery that do not apply at open operation. At laparotomy the omentum is usually readily brought up to cover the ulcer. We have found that at laparoscopy, although the omentum can be brought up to cover the ulcer it tends to slip caudally making the suturing difficult though not impossible. Occasionally previous surgery or inflammation tethers the omentum which then requires dissection to bring it up to the first part of the duodenum. Laparoscopic repair of a perforated duodenal ulcer has
one
Six patients (three female, three male), aged between 42 and 78 years, presented with an acute abdomen and a provisional diagnosis of a perforated ulcer. After initial resuscitation they were all laparoscoped within 12 h. Three ports were used. A 10 mm umbilical, 10 mm left and 5 mm right upper quadrant trocars were inserted. In each case an anterior perforation in the first part of the duodenum was identified and associated with significant peritoneal soiling.
The abdominal cavity was lavaged with copious volumes of normal saline. In two patients the ulcer was Correspondence to: Mr D Menzies MS FRCS, Department of Surgery, Colchester General Hospital, Turner Road, Colchester, Essex C04 5JL
Laparoscopic repair of perforated duodenal ulcers
stitches and ties three knots, a skill that should be acquired before any type of operative laparoscopy is attempted. While it is clearly possible to oversew an ulcer and patch it with omentum we have found in these few cases that the falciform ligament is an excellent, simpler alternative. We suggest that surgeons consider its use in this setting.
i-Fn G.B.
F.L. = Falciform ligament G.B. = Gallbladder DU = Duodenum
391
References
U = Ulcer OM = Omentum
Figure 1. The relationship of a duodenal ulcer to the falciform ligament as seen at laparoscopy.
been reported (5). This employs the same technique of omental patch as in an open operation. A number of reports have appeared trying to simplify the operation and avoid a difficult suture technique by using either fibrin glue (6,7) or a stapling device (8), but these have increased the number of ports required and necessitated the use of expensive equipment. In the undisturbed state the falciform ligament lies across the first part of the duodenum and so can be sutured to an ulcer without tension or mobilisation. As such the technique requires that the surgeon places three
1 McKernan JB, Wolfe BM, MacFadyen BV Jr. Laparoscopic repair of duodenal ulcer and gastro-oesophageal reflux. Surg Clin North Am 1992; 72: 1153-67. 2 Patterson-Brown S. Emergency laparoscopic surgery. Br J Surg 1993; 80: 279-83. 3 Darzi A, Carey PD, Menzies-Gow N, Monson JR. Preliminary results of laparoscopic repair of perforated duodenal ulcers. Surg Lap Endosc 1993; 3: 161-3. 4 Fry DE, Richardson JD, Flint LM. Closure of an acute perforated peptic ulcer with the falciform ligament. Arch Surg 1978; 113: 1209-10. 5 Sunderland GT, Chisholm EM, Lau WY, Chung SCS, Li AKC. Laparoscopic repair of perforated peptic ulcer. Br J Surg 1992; 79: 785. 6 Tate JJT, Dawson JW, Lau WY, Li AKC. Sutureless laparoscopic treatment of perforated duodenal ulcer. Br J Surg 1993; 80: 235. 7 Benoit J, Champault GG, Lebhar E, Sezeur A. Sutureless laparoscopic treatment of perforated duodenal ulcer. BrJI Surg 1993; 80: 1212. 8 Darzi A, Cheshire NJ, Somers SS, Super PA, Guillou PJ, Monson JRT. Laparoscopic omental patch repair of perforated duodenal ulcer with an automated stapler. Br J Surg 1993; 80: 1552.
Received 21 November 1995
