A combined laparoscopic - endoscopic operation of perforated gastric ulcer with gastric mucosa biopsy and use of great omentum as a vital material in ulcer perforation is described. The combination of endoscopy and laparoscopic surgical procedure allows a good insight into the pylorus and duodenum patency. Intraoperative biopsy of the antrum and gastric corpus mucosa provides a definite histologic finding concerning the possible presence of Helicobacter pylori. Besides fast patient recovery, the laparoscopic approach to perforated ulcer also allows for adequate irrigation, and drainage if necessary, of the abdomen.Opisana je laparoskopsko-endoskopska operacija perforiranog želučanog vrijeda s biopsijom želučane sluznice i aplikacijom velikog omentuma u otvor perforacije. Kombinacija endoskopskog i laparoskopskog postupka daje dobar uvid u prohodnost pilorusa i dvanaesnika. Intraperitonejska biopsija sluznice antruma i želučanog korpusa omogućuje konačnu histološku dijagnozu te daje potvrdu moguće prisutnosti Helicobacter pylori. Uz brzi poslijeoperacijski oporavak bolesnika, laparoskopski pristup perforiranom vrijedu omogućava zadovoljavajuću irigaciju i drenažu abdomena

August Mijić

Hrvoje Hochstadter

Krešimir Raguž

Marijan Huis

Miroslav Bekavac-Bešlin

Mladen Perić

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Acta clin Croat 2000; 39:161-163 Professional Paper161COMBINED ENDOSCOPIC · LAPAROSCOPIC OPERATIONOF PERFORATED GASTRIC ULCER WITH OMENTOPLASTYMiroslav Bekavac-Be¹lin1, August MijiÊ1, Hrvoje Hochstadter1, Mladen PeriÊ1, Kre¹imir Raguæ2 andMarijan Huis31Department of Surgery, Sestre milosrdnice University Hospital, Zagreb, 2Department of Surgery, Dr. Josip BenËeviÊGeneral Hospitall, Slavonski Brod, and 3Department of Surgery, Cvijeta Huis General Hospital, Zabok, CroatiaSUMMARY · A combined laparoscopic · endoscopic operation of perforated gastric ulcer withgastric mucosa biopsy and use of great omentum as a vital material in ulcer perforation is described.The combination of endoscopy and laparoscopic surgical procedure allows a good insight into thepylorus and duodenum patency. Intraoperative biopsy of the antrum and gastric corpus mucosa pro-vides a definite histologic finding concerning the possible presence of Helicobacter pylori. Besides fastpatient recovery, the laparoscopic approach to perforated ulcer also allows for adequate irrigation,and drainage if necessary, of the abdomen.Key words: Peptic ulcer, surgery; Peptic ulcer, complications; Laparoscopy, methods; Omentum, surgeryCorrespondence to: Miroslav-Bekavac Be¹lin, M.D., Ph.D., Depart-ment of Surgery, Sestre milosrdnice University Hospital, Vinogradskac. 29, HR-10000 Zagreb, CroatiaReceived May 22, 2000, accepted in revised form August 17, 2000IntroductionUlcer disease has now definitely ceased to be a con-traindication for operative treatment, and the diagnosis ofduodenal or gastric ulcer is daily encountered in opera-tive schedules of surgical departments. However, compli-cations of ulcer disease are still present, and so is the is-sue of proper choice of the techniques and procedures tobe used in the management of these complications, rais-ing vigorous discussions, both in the literature and at par-ticular surgical departments1-3.The technique described is not a complete novelty4,5.It is a combination of two standard methods used in themedical treatment and diagnosis of ulcer disease and itscomplications, i.e. laparoscopy and endoscopy. Satisfac-tory results have been reported from two centers. Ourresults confirmed the value of the method. It should beemphasized that the combined endoscopic · laparoscopicmethod ensures complete therapeutic management of oneof the ulcer disease complications, i.e. gastroduodenalulcer perforation.The ’70s were the turning point in the treatment ofulcer disease. Efficient conservative antiulcer therapy en-abled fast healing of the ulcer, while interventional diges-tive endoscopy contributed to the predominance of con-servative treatment for ulcer disease. The ’80s brought newconcepts on the genesis of ulcer disease. Helicobacter (H.)pylori was demonstrated to be the main cause of gastritisand ulcer disease. Ulcer was found to be efficiently curedand its recurrence prevented by a combination of antibi-otic therapy (Sumamed  for 3 days and Amoxyl for 7 days)and omeprazole (for 4 weeks).The ’90s were characterized by considerable changesin surgery. The minimally invasive surgery has brought a‘revolution’ to the domain of traditional surgery, and videosurgery has soon become part of standard procedures inthe management of malignant and benign diseases of thestomach.Patients and MethodsCombined endoscopic · laparoscopic operation ofperforated gastroduodenal ulcer was performed in six pa-M. Bekavac-Be¹lin et al. Combined surgery for perforated gastric ulcer162 Acta clin Croat, Vol. 39, No. 3, 2000tients, four patients with duodenal ulcer perforation andtwo patients with gastric ulcer (anterior wall) perforation.There were four men and two women, mean age 40. Thepatients had not been previously treated for ulcer disease.The time elapsed from ulcer perforation to hospital ad-mission ranged between five and nine hours. All patientswere operated on immediately upon admission.The operation was performed under general anesthe-sia. Upon CO2 insufflation to 14 mm Hg, four trocarswere inserted (three 10-mm and one 5-mm). The fourthtrocar was inserted in case the liver had to be retracted.Upon exploration of the abdomen and thorough irriga-tion of the subphrenic space, paracolic space, interintes-tinal spaces, and bottom of the pelvis, the surgeon pro-ceeded performing omentoplasty and fixation of theomentum by suture.Then, a gastroscope was introduced, and in case ofgastric ulcer biopsy of the ulcer edge was performed. Bi-opsy material was examined for the presence of H. pylori.Patency of the pylorus and duodenum was controlled.Biopsy forceps were used to pull the omentum throughthe ulcer perforation and to seal the opening.Two stitches were enough for fixation of the omen-tum to the gastric wall or duodenum. The abdomen wasirrigated with saline, and drainage was used in the patientswith a history of ulcer perforation exceeding 8 hours. Thedrains were placed on the trocar entry points and takenout after 24-48 hours. The nasogastric tube was removedon day 4 postoperatively. The patients received antiulcertherapy (H2-blocker) which was modified in case of veri-fied presence of H. pylori.The patients underwent endoscopic control examina-tions at 3 and 6 weeks after the surgery.ResultsThe combined laparoscopic · endoscopic method wassuccessfully used in six patients with duodenal or gastriculcer perforation. There were no perioperative or postop-erative complications. The duration of the operation was70 minutes on an average. All patients were pretreatedwith antiulcer and antibiotic therapy (cephalosporin). Ashistologic findings proved the presence of H. pylori in allthe six patients, the antibiotic treatment was changed toamoxicillin, 2 x 1 g, for seven days, and Sumamed, 1 g/day, for three days. Therapy also included Ultop for fourweeks. The wounds healed per primam intentionem. Thepatients were discharged in 7 days on an average. Con-trol endoscopic examination performed at three weeksshowed a scar at the site of omentoplasty, whereas at sixweeks it was difficult to discern the site of perforation.Adequate patency of the pylorus and duodenum wasendoscopically proved in all the six patients.DiscussionThe combined endoscopic · laparoscopic method inthe treatment of perforated gastroduodenal ulcer was in-troduced at the Department of Surgery, Sestre milosrdniceUniversity Hospital from Zagreb at the beginning of1995. The method has been quite infrequently employedbecause it requires the presence of a surgeon trained inlaparoscopic surgery and an endoscopist, which is not al-ways easy to accomplish in our circumstances. Therefore,a great proportion of patients have still to be operated onby the classical surgical technique.We find this operation is easy to perform from thetechnical point of view, secures the site of perforation, andcan be used in case of the gastric ulcer posterior perfora-tion (the omentum can be modelled, if necessary). Thesize of the perforation opening is irrelevant, because therealways is enough omental material for sealing.The laparoscopic method ensures that all criticalpoints are readily visible, while irrigation and drainage areeasy to perform if necessary. Also, drains can be placed atmore ‘critical’ sites. The help of endoscopy is extremelyvaluable, while histologic verification of suspect materialand detection of H. pylori completes the diagnostic andtherapeutic procedure6. The tolerance of the operation isby far better than that of a classical one. The patients getup from their beds sooner and are discharged from thehospital 2-3 days sooner than after classical operative pro-cedure. In our series, endoscopic controls performed atthree and six weeks showed neat healing of the ulcer andexcellent patency of the pylorus and duodenum.If intraoperative biopsy of perforated ulcer marginindicates a carcinoma, open gastrectomy or ventricular re-section should be performed.ConclusionThe combined endoscopic · laparoscopic omento-plasty for perforated gastroduodenal ulcer is a relativelynew (in hospital practice) and recognized method. Themethod incorporates the value of minimally invasive sur-M. Bekavac-Be¹lin et al. Combined surgery for perforated gastric ulcerActa clin Croat, Vol. 39, No. 3, 2000 163SaæetakKOMBINIRANA ENDOSKOPSKO LAPAROSKOPSKA OPERACIJA PERFORIRANOG ÆELU»ANOG VRIJEDAS OMENTOPLASTIKOMM. Bekavac-Be¹lin, A. MijiÊ, H. Hochstadter, M. PeriÊ i K. RaguæOpisana je laparoskopsko-endoskopska operacija perforiranog æeluËanog vrijeda s biopsijom æeluËane sluznice i aplikacijomvelikog omentuma u otvor perforacije. Kombinacija endoskopskog i laparoskopskog postupka daje dobar uvid u prohodnostpilorusa i dvanaesnika. Intraperitonejska biopsija sluznice antruma i æeluËanog korpusa omoguÊuje konaËnu histolo¹ku dijagnozute daje potvrdu moguÊe prisutnosti Helicobacter pylori. Uz brzi poslijeoperacijski oporavak bolesnika, laparoskopski pristupperforiranom vrijedu omoguÊava zadovoljavajuÊu irigaciju i drenaæu abdomena.KljuËne rijeËi: perforirani vrijed, laparoskopska kirurgija, endoskopija, omentoplastikagery and digestive endoscopy. The arguments that speakin favor of the method include the possibility of goodintragastric and extragastric exploration; detection of ma-lignancy and bacterial invasion; and healing of defectswith autologous material.References1. KIRKPATRICK JR, BOUWMAN DL. A logical solution to theperforated ulcer controversy. Surg Gynecol Obstet 1980;150:683-6.2. WATKINS RM, DENNISON AR, COLLIN J. What has hap-pened to perforated peptic ulcer? Br J Surg 1984;71:774-6.3. BEKAVAC-BE©LIN M, GEORGIJEVIÆ A, ©ENI B. Reo-perations of patients with sutured perforated duodenal ulcer. XXVIntersectional Meeting of the Croatian and Slovenian Surgeons,Book of Abstracts, 1986.4. COSTALAT G, ALQUIER Y. Combined laparoscopic and en-doscopic treatment of perforated gastroduodenal ulcer using theligamentum teres hepatic (LTH). Surg Endosc 1955;9:677-680.5. DAWSON JW, TATE JJT. Coelioscopic treatment of perforatedgastroduodenal ulcer. Gut 1992;33:S16.6. MIJIÆ A, BEKAVAC-BE©LIN M, VUKADINOVIÆ MV et al.Helicobacter pylori and peptic ulcer disease. Endoscopic · micro-biological correlation. Acta Clin Croat 1991;30:63-6.7. KATHOUDA N, MOUIEL J. Laparoscopic treatment of pepticulcer disease. In: HUNTER JG, SACKIE JM. Minimally invasivesurgery. New York: McGraw-Hill, 1998:123-30.

Kombinirana endoskopsko laparoskopska operacija perforiranog želučanog vrijeda s omentoplastikom

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Kombinirana endoskopsko laparoskopska operacija perforiranog želučanog vrijeda s omentoplastikom

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